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BUFORD J. 

EDITH M. 




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fiOEXRIGHT DEPOSIT. 



HEALTH EDUCATION 
and the NUTRITION CLASS 



HEALTH EDUCATION 
and the NUTRITION CLASS 

A Report of 
The Bureau of Educational Experiments 

Descriptive and Educational Sections 
By JEAN LEE HUNT 

Studies of Height and Weight and Mental Measurements 
By BUFORD J. JOHNSON, Ph.D. 

Report on Physical Examinations 1919-20 
By EDITH M. LINCOLN, M.D. 




New York 
E. P. DUTTON & COMPANY 

681 Fifth Avenue 



Copyright, 1921 
By E. P. DUTTON & COMPANY 



All Rights Reserved 



I 



DEC 19 1921 



£ 



■ , 



Printed in the "United States of America 

©CU680907 



TO 

^lizabeify #pragi» €atilttt$t 

WHOSE GENEROSITY HAS MADE POSSIBLE 

WHATEVER CONTRIBUTION THIS STUDY MAY OFFER 

TOWARD THE BETTER KNOWLEDGE OF CHILDHOOD, 

AND THE INCORPORATION OF SUCH KNOWLEDGE 

IN THE SCHOOL'S PRACTICE AND THINKING 



ACKNOWLEDGMENTS 

To recall the history of the Nutrition Classes at 
P. S. 64 is to recall devoted service and generous 
contributions of many kinds and from many sources. 
The text of our report in itself reflects the coopera- 
tive nature of the undertaking, compiled as it is from 
a diversity of special and partial reports made by 
different workers at various stages of the experi- 
ment. We desire to make special acknowledgment 
to the following: 

To Harriet M. Johnson who as our General Sec- 
retary organized the experiment, secured the neces- 
sary facilities for it and the requisite permissions 
for its conduct from the school and city authorities, 
and who enlisted the cooperation of the chief workers 
and agencies identified with the undertaking. 

To Harriet Forbes, at whose suggestion the ex- 
periment was first initiated and whose untiring 
efforts have been directed to the improvement of 
technique for the enlistment of cooperation from the 
children and from their parents. Miss Forbes has 
been responsible for the programs of class instruc- 
tion and home contacts in the second and third years 
of the work, and has contributed the social study 
used as the basis of Chapter II. 

To Frederick W. Ellis whose reinterpretation of 
early results in the light of later findings has con- 



viii ACKNOWLEDGMENTS 

tributed greatly to the value of our report and whose 
advice and criticism have been invaluable throughout 
the experiment. 

To Dr. William E. P. Emerson who assisted in the 
organization of the work and directed it in its earlier 
stages and to his co-worker, Miss Mabel Skilton. 

To Dr. David Mitchell who made the computa- 
tions of statistical material gathered in the first and 
second years of the experiment, compiled the tables 
and devised the charts used in Chapters III and IV. 

To Miss Bessie Edwina Beckwith, and Miss 
Louise Schriefer who as members of our staff have 
made individual contributions to methods employed 
and data submitted, and to Miss Mary Marot, our 
Educational Recorder, for the reports of class pro- 
cedure incorporated in Chapters III and IV. To 
Miss Margaret Vanderbilt and Miss Margaret Cobb 
who have given volunteer assistance of the greatest 
value. 

To Superintendent William L. Ettinger of the 
New York City Schools and to Dr. Gustave Straub- 
enmuller, Acting Superintendent of Schools at the 
time our experiment was initiated, for the permis- 
sion by which we were enabled to conduct our classes 
in a public school. 

To Dr. Louis N. Marks, Principal, and those 
teachers of P. S. 64 who by their interest, sympathy 
and daily cooperation have made the experiment 
possible. 



ACKNOWLEDGMENTS ix 

To Dr. Josephine D. Baker and Dr. Leopold 
Marcus, of the New York City Bureau of Child 
Hygiene, through whose kind cooperation we ob- 
tained the special facilities of open-air class-rooms 
for many of the children under our care. 

To Dr. Howard Foster, and to Bellevue Hospital, 
the Metropolitan Hospital and the Post Graduate 
Hospital, for generous assistance in cases requiring 
special examinations or operation for tonsil and 
adenoid defects. 

To Dr. Harold A. Koonz and Dr. Louis A. 
Leichter for generous contributions of professional 
services in the correction of dental defects, and to 
the workers of the Stuyvesant Clinic and the Twenty- 
third Street Clinic for the assistance rendered by 
them. 

To the workers of Christodora House and to the 
New York School Lunch Committee of the Associa- 
tion for Improving the Condition of the Poor for 
their cooperation in the program of school feeding 
during the first term of the experiment. 

To Dr. Robert Kahn and his assistant, Mrs. B. 
G. Reid of the New York City Department of Health 
Eye Clinic for their unfailing interest and coopera- 
tion during the entire period of our work, and to 
Dr. I. H. Goldberger of the New York City Depart- 
ment of Health for the special physical examinations 
made by him of children under our care. 



FOREWORD 

By publishing this detailed study of our experi- 
ment with nutrition classes in a city school, it is our 
hope to place at the disposal of other workers such 
an account of the experience, of the questions raised 
by it, and of the varying degrees of success and fail- 
ure attending it, as may serve materially to further 
the success of other enterprises in the same 'field 
of service. The experiment has brought to us 
clearer understanding of the essential problems of 
health education, and better appreciation of its true 
scope and possible place in general educational pro- 
cedure. If our readers will consider with us the 
successive problems incident to our work at the dif- 
ferent stages of its development, we believe they 
will arrive with us at that inevitable conclusion of 
educational experiment, the beginning of further 
experiment, with enlarged knowledge and improved 
technique in prospect. Only thus may we account 
our undertaking successful and our record to have 
served its purpose. 

The Bureau op Educational Experiments. 

New York City, 
June, 1921. 



XI 



CONTENTS 

PAGES 

CHAPTER I 
Place of the Experiment 

Premises — The General Health Problem — The Problem 
of Malnutrition — Some Misconceptions — Inadequacy 
of Attack — The Experiment Outlined 1-13 

CHAPTER II 
The Social Background 

The School Population — Home Environment — School En- 
vironment 14-26 

CHAPTER III 
The Initial Program 

Descriptive Report — Statistical Data and Interpretations 

— Summary 27-61 

CHAPTER IV 
Development of Procedure — Grammar Grades 

Descriptive Report— Statistical Data and Interpretations 

— Summary 62-97 

CHAPTER V 
Development of Procedure — Primary Grades 

Descriptive Report — Report on Physical Examinations 98-117 

CHAPTER VI 
Growth in Height and Weight 

Distribution of Percentages Under and Overweight — 
Comparison of Underweight and Control Groups — 
Seasonal Variation— Comparison of Varying Degrees of 
Percentage Underweight — Variations in Type — Inter- 
pretations — Summary of Procedure 1919-20 118-158 

xiii 



xiv CONTENTS 

PAGES 

CHAPTER VII 
Mental Measurements of First Grade Children 

Group Selection — Apparatus and Procedure — Tabulation 
of Results — Comparison of Nutrition and Control 
Groups — Motor Coordination of Nutrition Group — 
Summary 159-198 

CHAPTER VIII 

Interpretations and Recommendations for a 
Program of Research 

Standards of Growth — Causal Factors and Response — 

Psychological Implications 199-220 

CHAPTER IX 

Interpretations and Recommendations for an 
Educational Program 

Principles Determining Results — Criteria for Educa- 
tional Experiences in the Health Program — Impli- 
cations for School Procedure— Summary 221-257 

Appendices 258 



ILLUSTRATIONS 

Mid- morning Lunch at Christodora House 28 

Rest and Restlessness in the Gymnasium at Christodora 
House 44 

Comparing Progress — Open-air Boys of 1918-19 62 



xv 



HEALTH EDUCATION 
and the NUTRITION CLASS 



HEALTH EDUCATION 
AND THE NUTRITION CLASS 



CHAPTER I 

PLACE OF THE EXPERIMENT 



PREMISES 



The experiment here recorded was undertaken to 
explore the possibilities of the nutrition class in a 
public school, to determine how far a school can 
successfully employ the nutrition class procedure, 
and in particular how far the procedure itself can 
be expected to reinforce the school's general pro- 
gram of health education. Our classes at Public 
School 64, Manhattan, have constituted, we believe, 
the pioneer attempt to remedy malnutrition in a 
school population by employing the methods of the 
hospital nutrition clinic or class within the school. 
In conducting them, however, we have had broader 
educational interests very definitely in view, and our 
aim has been primarily the enrichment of general 
educational procedure rather than the development 
of special provisions for children needing particular 
care. 

The health program of the school, if it is to be 
developed in accordance with educational conceptions 

l 



2 HEALTH EDUCATION 

of the present day, must conform to the general 
thesis that the child's environment shall afford the 
conditions for certain necessary experiences, and 
that his intelligent cooperation with regard to these 
experiences must be secured; it must give to the 
school and to the individual child within the school 
a creative attitude toward the problem of health; 
it must function appreciably in better habits of 
health and in better individual well-being. 

Moreover, if such a school program is to be ade- 
quate as a health program, its development requires 
the services of the physician and of other specialists 
in several fields of science, for the school cannot be 
expected to take over and handle through its regular 
professional staff a serious attack on the technical 
problems involved. Thus the situation of the school 
in regard to health education is characteristic of its 
situation with regard to any supplementary activity 
involving a considerable body of specific knowledge 
or particular technique for its conduct. The great 
majority of teachers to-day are but inadequately 
equipped, so far as understanding of the science and 
technique of their own profession is concerned. To 
demand that the class-room teacher shall be conver- 
sant with any considerable outside body of scientific 
facts or any highly developed technique belonging to 
another profession, is to demand the impossible. It 
is only as specialists from other fields can enter the 
school, introducing their own techniques and adapt- 
ing them to the school's requirements, that their 
various contributions to the service of childhood can 
be successfully incorporated with school activities. 



PLACE OF THE EXPERIMENT 3 

and the school's thinking and service correspond- 
ingly broadened. 

It is in this field of educational experience that the 
Bureau of Educational Experiments has been par- 
ticularly interested to work. The position of the 
school makes it the logical clearing-house for those 
members of the community who hold in their united 
thinking the community's available knowledge in 
regard to children and their needs, and the attempt 
to bring together cooperatively the school and the 
specialists best prepared to deal with children's 
problems, presents in our estimation an opportunity 
for educational experiment offering particular 
promise for the future. 

Thus a number of considerations led us to experi- 
ment with the nutrition class as a tentative proce- 
dure in a school program. It was in essential agree- 
ment with our educational thesis. It necessitated 
introducing within the school the services of the 
pediatrist and of his trained social service assistants 
and relating their special knowledge and techniques 
as closely as possible to the school's problems and 
the school's thinking. It offered an attack on health 
from the positive side. If by its adoption the school 
could secure a satisfactory procedure and appre- 
ciable gains for underweight children, we believed 
it would at the same time serve to demonstrate the 
essential features of a general program of health 
education much needed at the present time. 

THE GENERAL HEALTH PROBLEM 

"We have had abundant illustration during the 
years just past of the importance of physical fitness 



4 HEALTH EDUCATION 

to the national life. Attention has been increasingly 
focus sed on problems of public health and it has been 
unnecessary to contemplate disasters in foreign 
lands for our own experience with such epidemics 
as those of " polio" and "flu" have brought into 
general public consciousness the importance of meas- 
ures for health conservation. We have all witnessed 
the dramatic sequence of events attending army re- 
cruiting, — the rejection of great numbers of young 
men because of physical defects, the raising to maxi- 
mum physical well-being of the men in training 
through the carefully regulated regime of the camp,* 
and to-day the third stage of the object lesson, the 
waning of that standard of well-being among the men 
mustered out as they go back to the daily occupations 
and ill-regulated regime of American private life. 

Possibly no circumstances less dramatic would have 
served to arouse public consciousness to the needs 
of the situation. Certainly there is throughout the 
country to-day a very general interest in problems 
of public health and a desire for betterment. The 
outstanding fact that must be evident to all is the 
need of a nation-wide program of prevention rather 
tli an correction, and the inadequacy of such limited 
lines of attack as military training and athletic pro- 
grams on the one hand, and the traditional activities 
of medical and welfare agencies on the other. 

THE PROBLEM OF MALNUTRITION" 

The problem of malnutrition among school chil- 
dren plays an important part in this general health 

* Chamberlain, Col. Wm. P., Effects of Army Life on the Health 
of Men, Proc. Int. Conf. Women Physicians, Vol. I, p. 244. Womans 
Press, 1920. 



PLACE OF THE EXPERIMENT 5 

problem. It is claimed to be largely responsible for 
after ills and weaknesses in later life. Its chief 
causes are main factors in the general public health 
problem, and a successful attack upon it in any group 
or community may be assumed to typify in miniature 
the kind of attack required in any comprehensive 
campaign on a nation-wide scale. 

Prevalent as the condition is to-day it was hardly 
recognized as a school problem ten years ago. We 
have only to examine the past reports of school 
medical inspectors to realize how little it figured in 
their thinking. Take for example the figures given 
for New York City Schools in 1911 * where malnu- 
trition is reported as affecting 2.5% of the total 
number of children examined, and compare them 
with the total of 17.7% similarly reported in 1920. t 
A survey of 43 schools in the poorer districts of the 
city made in 1918 revealed a percentage in one school 
population of 61% affected and 32% as the average 
found for the whole number surveyed.! While these 
last figures represent extreme conditions and at once 
suggest questions as to the standards used in obtain- 
ing them, the testimony of school and health author- 
ities the country over, in rural as well as in urban 
communities, is unanimous in its emphasis on the 
prevalence of the condition. 

We may account for this astonishing increase only 
by taking into consideration two types of factors 
that have been working consistently toward it 

* Gulick and Ayres, Medical Inspection of Schools, Eussell Sage 
Foundation Monograph, 1913, Table p. 40. 

t Monthly Bulletin, Dept. of Health, City of New York, May, 1921. 

t Baker,' Josephine D., Annual Report, Bureau of Child Hygiene, 
Dept. of Health, City of New York, 1918. 



6 HEALTH EDUCATION 

in recent years. First among these is the grow- 
ing recognition of the condition as one of ill-health, 
or at least of ill-being. A few years ago only ex- 
treme cases were recognized. With greater knowl- 
edge, however, has come the emergence of standards 
for diagnosing malnutrition, among them the now 
generally accepted height-weight-age index. Such 
standards as we have are still most imperfect, yet, 
such as they are, they are widely accepted and play 
an important part in the rise of the percentage 
reported to-day as against that reported ten years 
ago. 

Developing standards of nutrition do not, how- 
ever, sufficiently account for everything. The 
lowered standard of living during the war period, 
when certain necessary commodities, as butter-fats, 
meats and sugar, became scarce and unduly expen- 
sive, and the increased cost of living exceeded in the 
majority of homes whatever increase to the family 
income was contributed by the rising wage-scale, 
has undoubtedly been an important factor. Yet, in 
this country where little actual want existed, where 
even in the greatest crises of the war food has been 
sufficient and employment general, the resulting 
drop in the standard of well-being among our children 
seems to demand further explanation. The theory 
that the average standard of living in American 
homes does not provide for the maximum well-being 
of the individual, and is indeed so near the margin 
of ill-being that it permits of no reduction without 
an immediate resulting drop below the safety line, 
probably offers the most satisfactory hypothesis and 



PLACE OF THE EXPERIMENT 7 

one that the workers concerned in our experiment 
are ready to support. 

SOME MISCONCEPTIONS 

When during the winters of 1917 and 1918 the 
rapidly increasing percentage of malnutrition among 
children began to occupy the attention of the public, 
popular misconceptions in regard to its causes, 
remedies, and results to the individual, became evi- 
dent. First among these was the relation between 
malnutrition and hunger. It was claimed that our 
schools were full of hungry children whose parents 
were unable to supply them with necessary food. 
Popular discontent and alarm at rising prices added 
to this belief, and the obvious remedy seemed to lie 
in the general provision of school lunches at nominal 
prices, and at public expense for those unable to pay. 

In the brief time that has elapsed, there has been 
a considerable accession of popular knowledge on 
this subject, and it is almost difficult to look back 
to-day and understand the uncertainty with which 
such statements were met three years ago. As long 
as our chief sources of information in regard to the 
existing malnutrition in any community were the 
welfare and hospital agencies, no comprehensive 
view of the situation was possible, for their inquiry 
was, perforce, limited to those candidates for relief 
applying at their doors. The experience of the pri- 
vate practitioner with individual cases hardly car- 
ried over into the general picture of the community 
and its needs, and the conditions in middle class and 



8 HEALTH EDUCATION 

wealthy homes were thus entirely excluded from the 
picture. 

Comparatively few as the community surveys of 
malnutrition through the agency of the schools have 
been, the light they have thrown on the relation of 
malnutrition to economic conditions has been clari- 
fying. Foremost among such attempts must be 
noted the survey of 1920 by the Elizabeth McCor- 
mick Memorial Fund in Chicago, where the height- 
weight-age index was applied to 10,000 children, rep- 
resenting several school populations from different 
sections of the city that presented wide contrasts in 
economic conditions. Among the statistics gathered, 
one school with a percentage of 57.7 of its enroll- 
ment underweight was reported from "a comfort- 
able semi-suburban neighborhood," as contrasted 
with 16.2% for one school of "the stockyards dis- 
trict." This is undoubtedly the clearest answer yet 
returned to the misconception that confuses hunger 
with malnutrition.* Hungry children may be pres- 
ent in our public schools, but their problem does not 
explain the more general one of malnutrition. 

Another popular conception frequently voiced and 
less easily answered is that malnutrition results in 
dulling the mental faculties, and that such children 
are mentally handicapped. That hungry children 
are incapable of using their school opportunities 
with the same degree of profit as well-fed children, 
hardly needs demonstration. With a clear picture 

* Wood, Mrs. Ira Couch, Nutrition Classes in the Chicago Schools, 
Modern Medicine, May, 1920. 

See too, Bliss, D. C, Malnutrition a ScJwol Problem, El. Sch. 
Journal, March, 1921 — where a similar survey in the schools of Mont- 
clair, N. J., is described. The poorest section of this city made the 
best record. 



PLACE OF THE EXPERIMENT 9 

of the facts before us, however, — that relatively few 
of the malnourished children in our schools are 
hungry cases, other questions arise, for another 
popular conception, still current in many sections, 
though not as general to-day as it was fifty years 
ago, is the idea that the child of full physical vigor 
is less likely to make a good student than one of 
lower vitality and less abounding activity. 

Inasmuch as science has been unable to return 
unmistakable answers to these and other theories, 
popularly held and confusing to the issue, the prog- 
ress of the nation as a whole toward better standards 
of well-being has been definitely retarded, and there 
still remains a considerable field of scientific en- 
deavor to be covered before replies can be presented 
in terms sufficiently popular and convincing. 

INADEQUACY OF ATTACK 

If the general conception of the problem has been 
obscured in the past because of the character of our 
sources of information, the attack on malnutrition 
has been subject to equally serious limitations, 
although the medical profession, social agencies, the 
school, have all contributed to the attempt. The 
medical profession and the social welfare agencies 
have of necessity focussed their efforts on the cor- 
rective side, working for immediate results to the 
individual. In recent years the development of social 
service departments in connection with our hospitals, 
and the emergence of the visiting nurse, the public 
health nurse, the hospital social service worker, have 
resulted in a closer relationship between the tech- 
niques of the social agency and of the medical pro- 



10 HEALTH EDUCATION 

fession, and the development of the nutrition clinic 
is a pooling of their techniques and common experi- 
ence. The attack of the school, however, until a very 
recent period, was a fairly isolated one. Recogniz- 
ing its essential function to be educational and pre- 
ventive it has been content for the most part to await 
long term results, and to make no attempt to evalu- 
ate its health procedure currently in terms of appre- 
ciable increase to individual well-being. The hygiene 
lesson of the physiology class, the work of the do- 
mestic science and home economics classes, with their 
instruction limited to girls, the school lunch service, 
too often existing where it existed at all, on a purely 
commercial basis, — none of these possible vehicles 
for health education can be proven (unless in some 
exceptional cases) to have functioned definitely in 
the community by the establishment of health habits 
and a better standard of physical fitness. Our de- 
partments of physical education at their best are 
concerned only with a limited portion of the whole 
field of physical education and, in our public schools 
at least, are for the most part entirely inadequate 
in their provisions for that portion of it that they 
do attempt to cover. The medical examiner and the 
school nurse, working it is true within the school 
building, can hardly be said to have affected educa- 
tional procedure. Their function has been rather 
to prevent the spread of infectious diseases, and, so 
far as malnutrition is concerned, to diagnose extreme 
individual cases and refer them to the private prac- 
titioner or the hospital clinic. Their work has con- 
stituted the school's attack on the corrective side 
and has been at best a negative one. Thus our 



PLACE OF THE EXPERIMENT 11 

schools cannot be said to have developed anywhere 
a comprehensive educational procedure calculated to 
function appreciably in better habits Of health, to 
develop a creative attitude on the part of the child 
towards his own health, or to lend itself to current 
evaluation in terms of individual well-being. 

THE EXPERIMENT OUTLINED 

It will be evident that a first requisite for success- 
ful experiment with nutrition classes as a school 
procedure is the cooperation of a pediatrist of stand- 
ing in his profession who can visualize the pos- 
sibilities of such an experiment and who in his own 
thinking emphasizes the educational attack. Dr. 
Wm. R. P. Emerson of Boston has been the pioneer 
among pediatrists in calling attention to the serious 
consequences of malnutrition among school children, 
and in recognizing its milder stages as a condition 
of ill-being if not of actual ill-health. He has long 
recognized the important part played by education 
in the successful treatment of such cases, and since 
1908 has used a technique in the nutrition clinic of 
the Massachusetts General Hospital, now widely 
known as the "Class Method," by which the work 
of the clinic is conducted along the lines of a class 
in school. A visit to one of these "nutrition classes' ' 
in the Spring of 1917 first suggested to a member of 
our organization the experiment subsequently tried 
by us, that of transferring the nutrition clinic or 
"class" as developed by Dr. Emerson in the out- 
patient department of the hospital to a public school. 

In the fall of 1917 we enlisted Dr. Emerson's in- 
terest in our plan, and later when we accepted the 



12 HEALTH EDUCATION 

offer of P. S. 64 as a school laboratory, we secured 
his services for organizing the work and training 
the necessary workers. From February, 1918, when 
the classes began, until June, 1919, Dr. Emerson was 
associated with us, at first in a supervisory, later 
in an advisory capacity. During the last year, 1919- 
1920, the experiment was continued with our own 
staff. 

The original program as agreed on with Dr. Emer- 
son was an adaptation of the procedure used by him 
in the clinic of the Massachusetts General Hospital.* 
Our special interests in the educational and research 
aspects of the experiment led first to certain changes 
of detail, and later to substantial divergence as to 
the methods employed. In addition, certain modifi- 
cations and developments were made to meet condi- 
tions imposed by the school and community environ- 
ment, and by unexpected situations that developed 
in the course of the work. 

In June, 1921, when the classes were discontinued, 
we were using a procedure differing in many re- 
spects from the initial plan, though never approxi- 
mating a general health program. Indeed it may be 
well to realize at this point that the adoption of the 
nutrition class procedure, by confining our work to 
underweight children, proved confusing to our ulti- 
mate purpose for the entire period. To the workers 
actually engaged the tendency was always for the 
corrective procedure to become the all-important 
consideration, and as increasing public recognition 
of the problem of malnutrition further emphasized 

* For a description of this procedure see Standards of Child Wel- 
fare, Publication No. 60, Conference Series No. 1. Children's Bureau, 
U. S. Dept. of Labor, 1919, pp. 238-241. 



PLACE OF THE EXPERIMENT 13 

the existing need of corrective work, our experiment 
was naturally looked to for practical suggestions as 
to the conduct of a corrective program in the school. 
Thus the corrective aspect has always played a 
larger part in the experiment than was anticipated 
by us and has largely dictated the lines of develop- 
ment followed. It is probable, however, that the 
experience has gained in some respects by this fact, 
for the increased emphasis placed by the corrective 
procedure on the securing of results to the individ- 
ual, reinforces an educational program at its weak- 
est point. 

In addition to special provisions for physical 
diagnosis and care of individuals showing defects 
or morbid conditions, the nutrition class calls for a 
daily regime of good eating habits, abundant food, 
frequent rest, constant fresh air. To provide 
adequate conditions in respect to these essentials 
the cooperation of the adults responsible for the 
twenty-four hour environment of the child is de- 
manded. It seems desirable, therefore, before dis- 
cussing the procedure used in detail, to describe the 
environmental conditions of the community in which 
we worked, both in the homes and at the school. 



CHAPTER II 
THE SOCIAL BACKGROUND 

THE SCHOOL POPULATION 

The necessary arrangements preliminary to the 
experiment were not completed until January, 1918, 
for in addition to enlisting the interest and securing 
the necessary permission from the school authorities, 
the question of a suitable school plant was one for 
serious consideration. For years the City of New 
York has been behind in its school-building program, 
and the increasing shortage of labor and material 
since 1914 has greatly increased the problem. The 
consequent overcrowding of the school-buildings has 
made space for additional activities problematical 
in the majority of schools, and this factor in itself 
rendered opportunities for a pioneer undertaking 
very limited. Quite as important was the problem 
of school population. As our undertaking involved 
intimate questions of home surroundings and habits 
of personal hygiene, considerations of economic 
status, racial stocks and foreign customs assumed 
particular importance for it. The desideratum 
would have been a school population representative 
of the typical American home, but the New York 
schools can offer few such opportunities. Instead, 
there is a choice of districts predominately Italian, 
Bohemian, Irish, Jewish, as against more hetero- 

14 



THE SOCIAL BACKGROUND 15 

geneous units. As to economic conditions, it was our 
purpose from the first to avoid the poorest districts. 
Obviously, those sections which furnish annually the 
greatest number of candidates for relief do not pre- 
sent an adequate opportunity for securing or evalu- 
ating results from an educational program. Public 
School 64, where we finally accepted the opportunity 
to conduct our classes, offered a fairly homogeneous 
Jewish population, in a section somewhat removed 
from the worst slums, though the neighborhood is 
crowded and unsightly. 

HOME ENVIRONMENT 

The social and home environment of the East side 
child has become fairly familiar through many care- 
ful reports* made in the general interest of child 
welfare, and for the purposes of this study it is prob- 
ably sufficient to discuss only those aspects which 
have particular bearing on the problem of nutrition. 
No thorough-going analysis of the economic situation 
is attempted, therefore, but rather a record of cer- 
tain problems reported by our home visitors, expe- 
rienced social workers who for years have studied life 
in the tenements and poverty in its varying degrees, 
and who in many cases have been admitted into the 
guarded confidence of the heads of families. That 
there is an abiding fear of want brooding over many 
homes where there is, at present, no acute distress 
is undoubtedly true, but there are also many families 
who regard their present surroundings merely as a 

* In particular see Dewey, Child and Euml, Methods and Results of 
Testing School Children, pp. 134 and 141-150, E. P. Dutton & Co., 
1920 — where the results of an intensive social study in an adjoining 
district presenting similar features are given. 



16 HEALTH EDUCATION 

foothold till they become prosperous enough to move 
where air and sunshine do not command so high a 
price. In none of the homes has there been evidence 
of inflated incomes due to war industry. Bather has 
it been true that with the majority there has been 
added hardship, due to the increased cost of living 
and to loss of their wage-earning members. Few of 
the mothers work outside of the home and a rela- 
tively small percentage take in work. Many parents 
have their own small business, the wife being occu- 
pied much of the time in helping her husband. In 
a number of cases rent is reduced or given free in 
exchange for janitor's service, largely performed by 
the mother in addition to her home duties. 

Relief was received by only a few of the families 
concerned in our study, though many more had at 
some time been known to charitable agencies. Self- 
help and self-respect are highly prized and jealously 
guarded. In those cases under our observation 
where illness or misfortune had resulted in the ac- 
ceptance of temporary relief, speedy return to a 
position of independence was usual. These sterling 
qualities and their attendant reserve rendered infi- 
nitely difficult the task of the nutrition worker whose 
problem is to secure modification of many of the 
intimate details of family life. 

As has been said, the population of this quarter 
is almost entirely Hebrew, the great majority being 
of Russian origin, the remainder are principally 
from Austria, with a scattering of Galicians, Hun- 
garians and Rumanians and a few Italians. The 
older generation is fairly orthodox, consequently 
there is present the serious problem of family dis- 



THE SOCIAL BACKGROUND 17 

integration and friction between older and younger 
members that obtains wherever such conditions are 
found. The public school is an important factor in 
this family problem for it is mainly through the 
school that the younger generation is Americanized. 
Our schools in the main have had but little under- 
standing of this situation in the foreign family, and 
few have developed a technique whereby the neces- 
sary instructions and messages to the home shall 
appear less like commands to the older from the 
younger generation, who are entrusted to deliver 
them. "You tell your mother," the usual teacher's 
formula, becomes an unthinkable medium for trans- 
mitting directions as to diet, sleep and clothing. The 
nutrition worker is keenly aware too of the impor- 
tance of strife and emotional disturbances in rela- 
tion to her problem.* A technique which will avoid 
any widening of this breach between parents and 
children must be hers if she would succeed, and her 
problem should offer more than a suggestion for 
general school practice when the foreign home is to 
be reached. 

Since the diet is in the hands of the mother, it 
remains true to tradition and unaffected by the fac- 
tors which are in process of modifying the lives of 
the younger generation. The standards imposed by 
the Hebrew ritual are strictly adhered to, and there 
is little realization of other standards. Ceremonial 
"cleanliness" is accepted as absolute cleanliness, 
with an acquiescence that is at times startling. Our 
workers found, however, no lack of food and of good 

* Camion, Walter B., Bodily Changes in Pam, Hunger, Fear and 
Bage, D. Appleton & Co., 1915. 



18 HEALTH EDUCATION 

food in the majority of homes. Insufficient knowl- 
edge of the properties of foods and faulty food 
habits were the evident factors militating against the 
adequacy of the home dietary. The long slow cook- 
ing which characterizes most of their dishes has its 
advantages in rendering food easily assimilable, but 
possibly results, too, in the loss of some of the 
essential vitamines with which the dietary as a whole 
is none too liberally supplied.* 

For years the public has been more or less 
aware that many children come to school with- 
out adequate breakfast, very many with no break- 
fast, and much restlessness and inattention, with con- 
sequent lowering of school standing is attributed to 
this fact. Social workers and conservative members 
of our school boards alike seem unaware of a similar 
problem existing in the private school when they 
argue for, and against, the supplying of mid-morning 
lunches, on the basis of economic insufficiency and 
the pauperization of the working home. Private 
schools to-day frequently provide a light lunch of 
cocoa or milk, and crackers or bread and butter for 
those children who in spite of long hours of care- 
fully guarded sleep with open windows, the invigo- 
rating tonic of the morning bath, and the well- 
appointed breakfast table, are without appetite for 
food in the early morning. On inquiry they will be 
found in any school. 

In homes like those of the children of P. S. 64 we 
may well consider whether any but the most robust 
appetite can survive the conditions surrounding 

* Schapiro, Mary L., Jewish Dietary Problems, Journal of Home 
Economics, Fob., 1919. This article well describes the characteristics 
of the Jewish dietary as found by us in the neighborhood. 



THE SOCIAL BACKGROUND 19 

breakfast time. In most instances every room in the 
flat including the kitchen is used for sleeping, and 
seldom has the individual child the common right 
of childhood to his own bed. Bed covering seemed 
adequate in all but a few instances, but the conti- 
nental fear of cold night air obtains, and windows 
are generally kept carefully closed, while for those 
able to afford it, the indoor air is further vitiated 
in winter by keeping the gas range burning through 
the night. In mild weather the conditions as to ven- 
tilation at night are hut little better, as the rooms 
are small, and at least two out of the four-room 
apartment receive their air only from a narrow inner 
court, often foul with odors from adjoining apart- 
ments. 

The congestion within the flat makes breakfast a 
disturbed meal. The older wage-earners of the fam- 
ily who must needs start away early, are given pref- 
erence over the school children, who have been late 
to bed and for whom the longer rest is needed. When 
finally roused the little people are torn between their 
desire to sleep and their fear of being late at school. 
With barely time for a hasty toilet and breakfast 
often eaten standing or walking about, the result is 
inevitable haste and strife on the part of the child, 
or an apathy which a nervous and irritable mother 
attempts to overcome. The result in either case is 
a disastrous one. The habit of crowding the mouth 
and washing down the food which prevails with 
large numbers of school children is often begun in 
this way and is most difficult to break down. The 
unfinished mastication and consequent shortening of 
the process of mouth digestion is no doubt frequently 



20 HEALTH EDUCATION 

the beginning of serious interference with digestion, 
and the accompanying hurry and irritation renders 
a thoroughly unsatisfactory meal even less desirable. 
The continental custom of serving only rolls and 
coffee for breakfast is the rule, and only occasion- 
ally does one find eggs or cereal added as a result 
of the propaganda for better feeding. In an appre- 
ciable number of homes, however, cocoa now replaces 
coffee for the children. 

The noon meal is usually a better one, though delay, 
in its preparation or too great haste in its consump- 
tion because of the child's desire to have time for 
play is often the cause of friction at home. It is 
the habit in some cases to have only a "snack" at 
this time, and to defer till school is over any attempt 
at a real meal. The three o 'clock meal of some sort 
is usual, and may or may not be a hearty one. In 
the main, convenience and economy urge that meals 
through the day be regarded rather as u stayers" 
until the wage earners shall return home, or the shop 
be closed, and the entire family can assemble for 
dinner, which is accordingly served late, often at 
eight or even nine o'clock. It needs little imagina- 
tion to realize that the children, after a long school 
day and hours of strenuous play in the street, are 
not able properly to digest this late meal, even were 
the menu planned with better regard for their years. 

The dinner consists usually of soup, which is re- 
garded as an essential dish, meat, frequently chicken, 
and such vegetables as potatoes, onions, beets and 
(cooked) cabbages. No salads or greens are found 
in the Jewish dietary and few puddings, though 
cakes of various sorts and pastry filled with fruit 



THE SOCIAL BACKGROUND 21 

or cheese are used. High seasoning and condiments 
characterize almost all the dishes, and pickles and 
mustard in quantity are rated among the essentials 
of a satisfactory menu even for quite little children. 
Much soda water is consumed between meals as well 
as cheap candy. The homes were found fairly well 
supplied with the more usual fruits, apples, oranges 
and bananas. 

The amount of milk used in these homes is for the 
most part far below the daily pint per individual 
recommended by Dr. Sherman of Columbia and 
others, and cutting down of the customary supply 
is one of the first economies to which the family in 
straitened circumstances has recourse. The Jewish 
restriction on the use of milk and milk products at 
any meal where meat forms part of the menu, limits 
the consumption of butter as well as of milk, and 
this restricted use of butter plays an important part 
in making vegetables less savory and therefore less 
popular than they should be. While there is a gen- 
eral understanding that " loose milk" should not be 
used until " boiled," ideas on the subject are far 
from clear. There is a general impression that all 
milk is unhealthf ul unless taken warm or hot, and that 
changes in its properties may attend heating is quite 
unknown. Even the best grade of bottled milk will 
often be placed immediately on the gas stove and 
allowed to heat indefinitely. It will be obvious that 
much of the dislike for milk found among the chil- 
dren may be traced to this method of treating it. 

Cold running water is supplied in these homes 
but bathing and toilet facilities are poor. In the 
majority of cases the occupants of the four or more 



22 HEALTH EDUCATION 

flats on a floor share a single toilet, ill-lighted and 
poorly ventilated. Even where more modern ap- 
pointments exist and the flat contains a bathroom, 
family habits are but little affected by the added 
facility and the school weight-taking discloses only 
too many grimy little bodies, whose clogged pores 
have little chance to play their part in the man-buiid- 
ing process. 

At the age of six the sons of the orthodox must 
begin attendance at the rabbi's school for instruction 
in the faith and in the Hebrew tongue. The sessions 
follow directly after dismissal from the public school 
and although the compulsory time is brief in the 
early years, at first only fifteen minutes a day, the 
little children are encouraged to stay after the ses- 
sions and, indeed, the younger ones are often sent by 
their mothers to be taken care of in the afternoons in 
the belief that they will be safer there than in the 
streets. Thus physical restraint in ill-ventilated sur- 
roundings is substituted for valuable hours of play 
in the open air, and the older boys who are prepar- 
ing for confirmation in the faith are often severely 
taxed by the requirements made of them in addition 
to the work and hours of their regular school day. 
It would seem as if, between the crowded home flat, 
the crowded school, and the after-school care of the 
rabbis, few stones were left unturned in the adult 
plan of this environment to cut the child off from 
activity in the open and a constant supply of fresh 
air. But were we to inquire as diligently into the 
environment provided by many " typical American' ' 
homes far removed from any kind of slum surround- 
ings, there is at least a probability of their affording 



THE SOCIAL BACKGROUND 23 

a fair parallel to the main features in this picture, — 
abundant food, inadequate dietary knowledge, poor 
eating habits, inadequate sleep and inadequate fresh 
air. 

SCHOOL ENVIRONMENT 

Public School 64 has one of the largest and best 
equipped school plants in the city and offers special 
facilities in its manual-training shops, auditorium, 
yard space, open air and ungraded classes. The 
principal, Dr. Louis Marks, is keenly interested in 
educational progress and has frequently cooperated 
with outside agencies in securing special activities 
and facilities for the school. Thus, the attitude, 
not only of the principal but of the teaching staff, 
is one of far greater interest, understanding and tol- 
erance for supplementary activities than is usually 
the case. Unusual opportunities for supplementing 
the school resources are to be found in the near 
proximity of Tompkins Square with its big play- 
ground and of such community agencies as the Boys ' 
Club on Avenue A, the nearby branch of the city 
library, and Christodora Settlement House, which 
stands adjacent to the school. 

Because of its extensive shop equipment the school 
has for some years been used almost entirely for 
boys, girls being admitted only in the Terman 
classes. (See p. 29.) This predominance of boys 
in the school population has had its effect on the 
experiment in certain particulars. Much of our 
work was concerned with the fifth and sixth grade 
boys, whom we must assume to be at that stage of 
prepubertal development characterized by minimum 



24 HEALTH EDUCATION 

growth when the individual is probably least able to 
respond to favorable conditions, and appreciable 
results from treatment are likely to be minimized. 

Food. — The time is not yet when the public school 
can gratify the small boy's native interest in food 
by admitting him to a cooking class, and domestic 
science equipment was, of course, entirely lacking 
as were lunch-room facilities. During the first year, 
when a mid-day meal was included in the nutrition 
program, it was supplied by the New York School 
Lunch Committee and served in Christodora House 
where special opportunities for rest periods were 
also provided. 

Fresh Air. — The importance of the air supply 
in relation to the processes of assimilation is too 
little understood, and public opinion in consequence 
too little informed, for school conditions generally to 
reflect the influence of scientific findings in regard 
to temperature, humidity and air movement. The 
equipment for heating and ventilation at P. S. 64 
is of the forced-air type generally accepted as the 
best in modern school building but is none the less 
open to some serious questions on the score of 
healthfulness. The atmosphere of the class-rooms 
in winter is undoubtedly better than would be found 
in the majority of our city schools, as more intelli- 
gent use is made of the facilities the equipment 
affords than is often the case, but it is probably no 
exaggeration to say that the air is at all times too 
warm, too dry, too still for the health of those who 
must spend long hours there five days a week. 

If by fresh air we mean cool air, in motion, and 
of optimum humidity, it must be evident, that except 



THE SOCIAL BACKGROUND 25 

for the groups in open-air rooms, the children of 
our nutrition classes did not receive a constant sup- 
ply during their school hours, nor probably at any 
other hours through the winter weather, save in their 
play time on the streets. 

Over-Fatigue and Bodily Activity. — By taking the 
children from active outdoor play for a considerable 
portion of the day and imposing the seated tasks and 
quiet of the class-room, there is no doubt that the 
school prevents much over-exertion on the part of 
the more delicate children. However, the probable 
loss to the average child resulting from the school's 
restraint of bodily activity and fixing of sedentary 
habits is of far greater importance for the general 
problem of health. Until the significance of this is 
more generally appreciated, however, school tradi- 
tion and equipment, together with the size of school 
classes, will continue to impose conditions where 
fatigue results from lack of bodily activity rather 
than because of it. There is, moreover, an inevitable 
nervous and physical stimulation for children in the 
mere presence of other children in numbers, and we 
may well ask ourselves the significance in terms of 
nutrition of the scrambling crowds gathered about 
the doors of P. S. 64 before each session, and of the 
general tension that necessarily attends the school 
day where 3000 boys are housed under a single roof. 
It seems evident that such conditions demand an 
increased expenditure of energy that must have a 
direct bearing on the nutritional processes of the 
individual. 

Additional Facilities. — P. S. 64 is well provided 
with toilet facilities and with running water and 



26 HEALTH EDUCATION 

drinking fountains. A fine gymnasium equipped 
with shower baths is available at the Boys' Club 
nearby and another is provided at Christodora 
House. These are used by many of the older 
children. 



CHAPTER III 

THE INITIAL PROGRAM, FEBRUARY-JUNE, 1918 

Basis of Selection 

STANDARDS 

The children selected for our nutrition classes 
were first measured for height and weight, the Burk- 
Boas Height-Weight- Age Tables being used as 
standards.* Those found to be 7% or more under- 
weight became candidates for enrollment, although 
it was never possible to enroll them all because of 
the administrative difficulties involved. The use of 
7% as a standard for determining malnutrition 
instead of the more usual 10% standard, was in ac- 
cordance with Dr. Emerson's opinion that 7% 
habitual underweight is indicative of a condition 
calling for attention. In our practice, however, 
because of the necessity the school was under of 
arranging definitely for the personnel of classes at 
the earliest possible date, the qualification " habit- 
ual" had to be disregarded and all children found 
7% underweight were admitted if provision could 
be made for them. While we realized that the adop- 
tion of so high a standard, especially for Jewish 
children of middle European antecedents, was open 
to question, we employed it tentatively throughout 

* Burk, Frederic, Growth of Children in Height and Weight, 
American Journal of Psychology, April, 1898. 

27 



28 HEALTH EDUCATION 

the experiment with a view to making an assessment 
of it, and of any special possibilities it might offer 
toward a program of preventive work. 

GROUP SELECTION 

Five classes were organized during the first year. 
A group of seventh grade, one of sixth grade, one 
of first grade children, a group of children from one 
of the regular open-air classes, and a group from the 
Terman or special classes, which existed as an experi- 
ment within the school, were included. In addition, a 
group of 20 fifth grade boys were selected and 
given a program of school feeding for purposes of 
comparison. The children from the upper grades 
were recruited in the belief that they were sufficiently 
advanced in school to cooperate intelligently in the 
experiment. The nutrition class procedure had been 
developed by Dr. Emerson with special reference to 
these older children, and the addition of the first 
grade group introduced problems of standards and 
of teaching methods not anticipated in his original 
plan. They were included because of an attempt on 
the part of the school to give particular care to mem- 
bers of the entering class, with a view to insuring 
individual adjustment to school life. It was believed 
that the nutrition class would supplement the school 
program effectively by affording special treatment 
for those showing need of physical attention. A 
program of health education carried out for six- 
year-olds seemed to offer, too, the logical beginning 
for a general health program in the school. The 
children of the open-air group were included partly 
because their condition as anaemic and pre-tuber- 



THE INITIAL PROGRAM 29 

cular cases demanded every assistance the school 
was able to afford, partly because their inclusion was 
the best response the school could offer to Dr. Emer- 
son's request for open-air treatment and a lighter 
program of school work. The Terman classes were 
included because of special interest of the school in 
them, and the fact that a surprisingly large percent- 
age of underweight was found to exist among them. 

THE TERMAN" CLASSES 

These classes consist of gifted children whose devi- 
ation from the average intelligence quotient repre- 
sents about the same range above normal as that of 
the defective in the ungraded classes does below. As 
children showing an I. Q. of 75 or less are placed 
by the school in special classes for defectives, so 
those showing an I. Q. of 125 or above have special 
provision made for them in the Terman classes. This 
experiment was in its initial stages at the time the 
nutrition classes began and was at that time limited 
to the sixth, seventh and eighth grades. In all, 69, 
children had been withdrawn from these grades and 
placed in two groups, one of which graduated in the 
spring of 1918, the other the following year. The 
average I. Q. was considerably beyond 125 and some 
individual ratings were much higher. The classes 
included girls as well as boys, and the age range 
was from ten to twelve years. 

The children in the more advanced group very 
generally exhibited the accelerated height increase, 
and consequent decrease of weight for height due to 
the approach of puberty. This factor undoubtedly 
contributed somewhat to the percentage of undeB? 



80 HEALTH EDUCATION 

weight recorded among them, as the Burk-Boas 
Height-Weight- Age Index is based principally on the 
measurements of children of other racial anteced- 
ents, in whom pubertal development presumably 
takes place at a less early age. They were, however, 
at no greater disadvantage in respect to this factor 
than were the children of the regular sixth and 
seventh grades who showed by the same standard 
percentages of 15.9 and 14.4 respectively in compari- 
son with the 27.5 average of the Terman class. A 
corresponding contrast is presented by the percent- 
age of overweight found among the Terman and 
regular grade children, the sixth and seventh grades 
showing a percentage of 18.7 overweight and the 
Terman groups a percentage of only 8.6.* 

The general impression created by these gifted 
classes, however, was one of physical superiority 
rather than the reverse. Their relatively poor show- 
ing in the initial height and weight taking created 
considerable surprise; and even after the stripped 
examinations had revealed the usual characteristics 
— winged scapulae, poor muscle tone, prominent rib 
bones, etc. — their faces, alert and often rosy, seemed 
to contradict the evidence. 

Possibly three-fourths of them came from homes 
distinctly above the general economic level of the 
district. This was primarily due to the higher aver- 
age intelligence of their parents, for whom the diffi- 
culties of getting a foot-hold in America had been 
reduced by their exceptional ability. A number were 
children of East side physicians who combined 

* Seven per cent or above in excess of normal is the basis on which 
this overweight is computed. See Distribution Table, Appendix A., 
also Tables I and II, pp. 49-50. 



THE INITIAL PROGRAM 31 

the advantages of education with those of superior 
intellect. The less prosperous represented families 
where some special factor, like relatively recent im- 
migration and consequent difficulty with a foreign 
language, kept the family fortunes at a lower level 
in spite of native ability. 

The members of the older class were looking for- 
ward to graduation in the spring, and were working 
under considerable pressure to prepare for the com- 
ing examinations. Ambition to excel was very gen- 
eral, and increased the high tension characteristic 
of the class as a whole. It is possible that over- 
stimulation had much to do with their condition of 
underweight and it is probably significant that 58% 
were borderline cases averaging less than 10% 
underweight. 

In providing for these children the school had not 
followed the usual rapid advancement plan by which* 
gifted pupils are put through the standard curric 
ulum in the shortest possible period. The attempt 
had been rather to broaden the school experience for 
those, who by reason of superior ability could best 
afford time for additional activities, and could be 
expected to profit most from them. A careful can- 
vass of neighborhood facilities had resulted in secur- 
ing for them special opportunities for library, play- 
ground and gymnasium activities, and instruction 
in music and drawing. The usual school discipline 
was considerably relaxed in the conduct of their 
classes, and their attitude toward every new interest 
and opportunity that was secured for them, was one 
of eager participation. Thus there had been much 
in their previous experience to prepare them for 



32 HEALTH EDUCATION 

benefiting from the suggestions of the nutrition 
class. 

Physical Care 

EXAMINATION AND DIAGNOSIS 

Every child enrolled in the class was given a care- 
ful stripped examination by one of the physicians 
to insure correct diagnosis and the prescription of 
treatment if conditions of disease were found to ex- 
ist, and to discover indications of physical defects 
calling for the advice and treatment of a specialist. 
Local legislation required that special permission 
from the parents must be obtained in every case 
before the stripped examination could be made, and 
this provision was always carefully followed. The 
nutrition worker secured the necessary permissions 
and urged the attendance of one of the parents at 
the examination in the hope of enlisting home inter- 
est and cooperation as far as possible from the start. 

The efficiency fetish which plays so important a 
part in public school thinking to-day, is only too 
likely to exert an undue influence on any program 
demanding the amount of individualization entailed 
by the nutrition class. Even our workers, who were 
under no necessity for observing standards other 
than thoroughness, and were free to expend time and 
care as the necessity of the individual required, felt 
keenly at first the desirability of making the experi- 
ment " efficient " from the school board viewpoint 
by limiting the time and effort expended to out- 
standing essentials, in the belief that the amount 
of time and work, and the consequent number of 
workers demanded, must be limited, so far as pos- 



THE INITIAL PROGRAM 33 

sible, in order to commend the undertaking to the 
school as a practical one. As experience increased, 
however, and our workers became better aware of 
the complex factors involved, the fallacy of confus- 
ing expedition with efficiency became more and more 
apparent. The time required for the examinations 
was found to average from twenty minutes to a half 
hour. 

THE CORRECTION OP DEFECTS 

Naso-Pharyngeal Obstructions. — Children who ap- 
peared to be suffering from physical defects bear- 
ing in any way on the nutritional processes were 
taken by the nutrition worker to one of the available 
clinics for re-examination by a specialist. Naso- 
pharyngeal obstructions were the chief concern, as 
the presence of tonsil and adenoid growths definitely 
reduces the underweight's ability to gain, and the 
effect of their removal has been aptly characterized 
as rendering him ' ' free to gain. ' ' The ideal program 
is therefore, to have all cases recommended for 
operation treated at as early a date as possible after 
the formation of the class. The attempt to secure 
these operations for children needing them involved 
much expenditure of time and effort throughout the 
entire period. It was generally difficult to persuade 
the parents of the necessity for such treatment, and 
as the facilities afforded by the city hospitals were 
limited, operations had often to be delayed after the 
parents' permission had been secured. Both Belle- 
vue and the Post-Graduate Hospital treated cases 
for us. In the five classes organized during this first 
term, 69 children, or 66% of the entire number en- 



34 HEALTH EDUCATION 

rolled were recommended for removal of tonsils or 
adenoids or both, and operations were secured for 
only 20 children, or 29% of the number needing 
them. In the majority of cases the treatment was 
delayed until the term was considerably advanced. 

Dental Caries. — Second in importance was the 
treatment or removal of carious teeth. No such 
obvious results in weight increase attend the remedy- 
ing of this type of defect as follow the removal of 
tonsils and adenoids. It was, however, always given 
an important place in our program, as an essential 
of any general health program where preventive as 
well as corrective work is the aim. Eighty-eight of 
our children out of the total 105 were persuaded to 
undergo examination by the dentist and of these, 63 
were found to have from 1 to 12 carious teeth. Treat- 
ment progressed slowly owing to the indifference of 
many parents, and the limited clinic facilities. The 
Stuyvesant Clinic and the Twenty-Third Street 
Clinic both treated dental cases for us. 

Eye Strain. — Examination for eye refraction was 
given in a few cases by request of the nutrition 
workers, but in general our staff did not assume 
responsibility for this type of defect as the Board of 
Health Eye Clinic, located in the building, provided 
excellent facilities for the children of the school. A 
strong prejudice against glasses, however, existed 
in the homes of the community and was shared by 
the children. Even after purchasing glasses few 
could be persuaded to wear them regularly in spite 
of strenuous efforts on the part of the nutrition 
worker and the class teacher to bring this about. 



THE INITIAL PROGRAM 35 

Cooperation of the Home 

CONTROL OF THE ENVIRONMENT 

The educational features of the nutrition class 
may be said to begin with the school and home en- 
vironment, and such opportunities as they afford for 
experience leading to proper intake of food, better 
digestion and increased assimilation. If children 
are to cooperate in a program of health experiences, 
certain conditions as to food, eating habits, fresh 
air, rest and sleep must be provided. How far the 
homes of the community could be enlisted to make 
necessary changes in customary habits, and how far 
they would be found able to do so, were therefore 
points of particular interest and importance for the 
experiment. By visits of the nutrition worker and 
the attendance of the parents at the weekly sessions 
of the class, we hoped to secure the necessary co- 
operation of the home in providing the following 
conditions : 

Food, — Adequate caloric intake averaging 2000 
calories a day. — While individual needs must de- 
termine variation in the figure, it was believed this 
amount would be found to constitute an increase 
over what the average child was receiving. — Mid- 
morning and mid-afternoon lunches, designed to add 
from 250 to 300 calories to the amount received at 
the usual meals. — These lunches were not to consist 
of foods like sweets calculated to take away the 
appetite for the regular meal. They were advised 
by Dr. Emerson on the theory that undernourished 
children, like invalids, will assimilate better if food 
is taken in smaller quantities at briefer intervals. 



36 HEALTH EDUCATION 

Diet. — To increase the caloric intake, milk and ce- 
reals were recommended, as the best foods by which 
the home table conld be supplemented for the under- 
weight child, with the least disturbance to family 
preferences and eating habits. The elimination of 
tea and coffee, and of any other stimulants the home 
table might afford, was especially stressed, as well 
as the necessity for an adequate breakfast. 

Prevention of Over-Fatigue. — A half hour rest 
period before the mid-day meal and avoidance of un- 
due physical activity, as roller-skating and ball- 
playing for protracted periods, and the need for 
proper hours of sleep with open windows, were es- 
pecially emphasized. 

Personal Hygiene. — In addition, the intelligent 
supervision of the home was sought in habits of eat- 
ing, bathing and elimination. 

HOME VISITING 

Permission for the stripped physical examination 
and the gathering of information concerning birth 
and infancy, previous diseases, and general health 
habits, with other social data regarding members of 
the family was the primary cause of home visiting 
by the nutrition worker, and required at least two 
visits to each family. Arrangements for securing 
the removal of physical defects when recommended 
necessitated further visits. During this first school 
term, however, a definite attempt was made to limit 
the home visiting and to make the necessary contacts 
with the parents through their attendance at the 
weekly class sessions. This was especially urged by 
Dr. Emerson, who was accustomed to securing the 



THE INITIAL PROGRAM 37 

attendance of mothers at hospital classes, and was 
anxious to develop the school nutrition class with 
as small a staff as was consistent with the demands 
of the situation. But the attempt to secure the 
mothers' attendance at the weekly class meetings 
was never very successful. The aversion of these 
foreign mothers to leaving their homes for any pur- 
pose outside the usual one of shopping and market- 
ing is very great, and their attendance as secured 
by the hospital clinic, is of itself indicative of their 
conviction that the children concerned are really ill. 
Where this is not obvious, it is often a slow process 
to convince either parent that any extra attention 
is needed. 

Cooperation of the School 

THE EYE CLINIC EOOM 

Through the courtesy of the Board of Health we 
were allowed to conduct our work in the one avail- 
able spot the crowded school building afforded. 
This was the eye clinic room, a class-room that had 
been set aside for that purpose. Sessions of the 
clinic were held here every morning, but after twelve 
the room was used only by the clinic nurse who 
worked at her desk, leaving the rest of the room free 
for the activities incident to the nutrition classes. 
Our equipment consisted of a Buffalo scale, a stadiom- 
eter, two screens, an examining table, and a cabinet 
file for records. Except for these, and the eye 
clinic desk and vision charts, the room presented no 
special features of equipment. Settees replaced the 
customary forms and desks, and offered certain ad- 
vantages in rearranging the room for our purposes. 



38 HEALTH EDUCATION 

These, with blackboards, and a table and chair for 
the teacher, constituted the furnishings. A good 
north light was secured from large windows along 
one side. When the classes met the children's charts 
were ranged against the blackboards in the back of 
the room for discussion. The screens were used 
when physical examinations were made or stripped 
weights taken. 

How far the work of the eye clinic may have been 
embarrassed or impeded by this partnership ar- 
rangement, we were never informed, for at all times 
our work and our workers received the utmost con- 
sideration and sympathy both from Dr. Robert 
Kahn, the oculist, and from Mrs. B. G. Reid, the 
nurse. If our own workers felt seriously the restric- 
tions imposed by the situation we cannot feel very 
sanguine over the effect of our strenuous program 
on theirs. At no time was it possible for the room 
to be given over entirely to the nutrition work, and 
the nutrition staff was always conscious of the neces- 
sity for conducting its work of weighing and measur- 
ing, checking up and recording, with the least pos- 
sible disturbance to the others. During the first term 
when Dr. Emerson's visits were frequent and his lim- 
ited time perforce divided among several classes, 
preparation for the class instruction had to be made 
even before Dr. Kahn had finished his regular clinic 
sessions. "When weights were taken the combined 
requirements imposed on the nutrition worker for 
accuracy in the records, quiet in a group of restless 
boys, and expedition, that the children might be re- 
turned to their class-rooms with the least possible 
loss of time, rendered the work particularly trying. 



THE INITIAL PROGRAM 39 

The difficulty of taking stripped weights under these 
conditions will be apparent, but the regular weekly 
weight-taking without shoes was in itself a sufficient 
problem. The first grade boys at the beginning of the 
term could not take off their shoes nor put them on 
without assistance, and for all ages it was apt to be a 
relatively slow process. Shoe laces with frayed ends 
were common, and they were often wet and knotted. 
Shoes and stockings, too, were frequently water- 
soaked. Nor could the littlest boys manage to pull 
off and on the tight-fitting sweaters that were uni- 
versally popular. 

The location of the room, overlooking the play- 
ground and next to the metal workshop, rendered the 
work of recording particularly difficult because of 
noises from outside, especially the shouts and cries 
of the second session children gathered about the 
doors waiting for their classes to begin.* To add 
to the responsibility of these sessions rapid dismis- 
sal signals (fire alarm) which could not be disre- 
garded were frequent, and visitors came at all times 
to observe our methods. It will be evident that 
whatever educational possibilities the experience of 
weight and height-taking might in itself have af- 
forded, were seriously impaired by the conditions 
under which these activities had to be conducted. 

CONTROL OF THE ENVIRONMENT 

In addition to furnishing headquarters for the 
work and facilities for the physical examinations, 
weekly weight-taking and class sessions, the school 
was asked to cooperate in the attempt at better con- 

* See p. 112. 



40 HEALTH EDUCATION 

trol of the environment. Compliance with Dr. Emer- 
son's request for shorter hours of work and open- 
window rooms for all the nutrition class pupils, 
seemed quite beyond the possibility of the situation 
except in the case of a few children, 11 in all, who 
because of pre-tubercular or anaemic condition were 
enrolled in one of the school's regular open-air 
classes. Opportunities for additional food intake 
and for rest periods were arranged during school 
hours but, partly for purposes of comparison, partly 
because it was found impossible to secure like op- 
portunities for all, the school program was varied 
for the different groups. Three of the classes were 
given a mid-day dinner with a value of approxi- 
mately 1000 calories. For four classes a special mid- 
morning lunch was arranged. Three classes had 
opportunities for a half hour rest during the school 
session, and the little group in the open-air class 
received the regular mid-morning lunch provided in 
all the open-air class-rooms. They had in addition 
the special facilities of the open-air rooms for rest- 
taking and fresh air, as well as a lighter program 
of work. The group of 20 boys from the fifth grade, 
received only the mid-day dinner and was not in- 
cluded in the general program of physical care and 
instruction. This group therefore in some particu- 
lars resembled a control group. The chief considera- 
tion in making these special provisions for different 
classes was a desire to determine the relative value of 
school feeding in the program. It was through the 
generous cooperation of Christodora House and of 
the New York School Lunch Committee that we were 



THE INITIAL PROGRAM 41 

able to secure the requisite facilities for this part of 
the work. 

MID-MORNING LUNCHES 

These were supplied and served by Christodora 
House to the children of the sixth grade, seventh 
grade, first grade, and Terman classes, and con- 
sisted of hot cocoa with crackers or bread and butter. 
The children enrolled in these groups went next door 
to the settlement to get this lunch beween ten and 
eleven o'clock every morning during ''out time ,, 
periods afforded by the school's double session 
schedule.* As the school was entirely without lunch 
room or domestic science equipment this appeared 
to be the only arrangement possible. It involved 
much extra time and loss of energy, especially in 
cold or stormy weather. Many of the children too 
were embarrassed and rebellious over other cir- 
cumstances attending it. The necessity of going 
for it when the other children did not, rendered 
them conspicuous, and " different " from their class- 
mates who did not fail to taunt them over their 
peculiarities. Thus many came only under protest 
after being ''rounded up" by the nutrition workers 
and "cutting" was frequent. Moreover, as no 
charge was made for the lunch, the stigma of 
"charity food" was attached to it at first, and many 
parents objected until its nature and purpose was 
fully explained to them. These difficulties became 
less as time progressed and most of the children 
came to understand and appreciate the significance 
of the nutrition program. The luncheon itself was 

* ' ' Out time, ' ' periods when the children are not in their class- 
rooms but are under supervision. 



42 HEALTH EDUCATION 

always acceptable to them and taken with apparent 
enjoyment, even by those who protested most vigor- 
ously over going for it. 

MID-DAY DINNER 

The mid-day dinner was supplied by the School 
Lunch Committee and delivered at Christodora 
House where service and supervision were furnished. 
Sixty-five children from the Terman, the sixth grade 
and the fifth grade groups received this meal. As 
the dining room capacity at Christodora House was 
limited to 35, the children were served in two groups. 
The menus were planned to provide 1000 calories and 
to broaden dietary habits with respect to vegetables, 
milk dishes, and cooked fruits. This deliberate at- 
tempt to supplement the deficiencies of the home 
dietary and develop a taste for new dishes, however 
excellent and important from the theoretical stand- 
point, presented very serious practical difficulties. In 
addition to the aversion felt by most children for un- 
accustomed dishes, the carefully inculcated prejudice 
of the Jewish child against strange foods, the fear 
that they may not be kosher, had to be reckoned 
with. This fear conditions the attitude of the Jew- 
ish child toward any unaccustomed food and greatly 
increases the difficulty of persuading him to eat new 
dishes. The high seasoning to which his home cook- 
ing accustoms him presents another serious problem. 
Bland and relatively delicate flavors are unappetiz- 
ing to palates demanding pickles, mustard and spice 
as a matter of course. In addition it must be re- 
membered that few, if any of these children could 
be classed as "hungry cases," and both the Terman 



THE INITIAL PROGRAM 43 

and sixth grade groups were receiving mid-morning 
luncheon in addition to dinner. Under the circum- 
stances it is not surprising that the children were 
indifferent to the dinner. Indeed, many of them were 
never persuaded to eat much, although as time pro- 
gressed the general attitude was better, as in the 
case of the attendance at the mid-morning luncheon. 
In the beginning there was much disorder and even 
" rough house" in the dining room. The intervals 
occasioned by the Easter vacation and the Jewish 
holidays at Passover broke up the continuity of the 
experiment, and during June, after the children had 
really begun to take the meal with some degree of 
satisfaction, the hot weather made serious inroads 
on appetite. Some concessions to the children's 
tastes, which the workers in charge felt could be 
made without sacrificing the nutritional and educa- 
tional value of the meal, were made. Such dishes 
as rice pudding and custards, for example, were given 
up, and desserts of cooked fruits substituted. Two 
sample menus reflecting this modification follow; 
as has been previously noted, they were planned to 
supplement deficiencies of the home dietary, not as 
model balanced meals.* 

Eice Soup (with milk) Potato Salad 

Mashed Potato and Turnip Eye Bread and Butter 

Eye Bread and Butter Prune Pudding 

Baked Apples Cocoa 

EEST PERIODS 

These were taken in the gymnasium at Christo- 
dora House for a half hour before the luncheon 
period. The sixth and seventh grade groups were 
required to take this rest period. The Terman 

* See Appendix D. 



44 HEALTH EDUCATION 

groups were advised to take it, and many of them 
did so. The children lay on the floor each wrapped 
in a blanket. There was always more or less diffi- 
culty in securing cooperation, especially from the 
older boys, and the task of supervising the rest 
period was not an easy one. The shouts and cries 
of their class-mates at play in the square outside 
could be plainly heard, and this made resting seem 
even more " babyish" than it already appeared to 
restless spirits. Occasionally one or two of the 
more obstreperous would decide to endure it no 
longer, and would suddenly cut out of the room, and 
escape to freedom. In spite of these disturbing ele- 
ments, there is no doubt that the children whose 
interest had been enlisted, succeeded in getting bene- 
fit from the period, and learned to lie quietly relaxed 
without being seriously disturbed by their more rest- 
less neighbors. 

Enlistment of the Child's Cooperation 

INDIVIDUAL INSTRUCTION 

To secure the second half of the educational 
program, the cooperation of the child within his en- 
vironment, both individual and class instruction 
were provided. Following the weekly measurements 
a brief interview between pupil and nutrition 
worker took place. Each child was given a specially 
devised booklet* containing a table of 100 calorie 
portions of common foods in which to record his 
food intake for 48 hours. He was asked to make a 
list of the actual food taken ; slices of bread, ounces 

* Emerson, Wm. E. P., A Record Boole for Measured Feeding, 
Pub. No. 3. Nutrition, Clinics for Delicate Children, Boston, Mass. 



THE INITIAL PROGRAM 45 

of milk, tablespoonfuls of cereal, etc. This 48-hour 
record was returned each week and the caloric in- 
take figured by the nutrition worker. 

Further data were obtained by the nutrition 
worker on the entire week's record with regard to 
observation of the prescribed program, rest periods, 
lunches, hours of sleep, drinking of tea and coffee, 
water at meals, fresh air, breakfast habits, rapid 
eating, exercise, fatigue, colds, clothing and any 
other facts of significance in the week's history. 
Notes made at the time of this interview were used 
later as a basis for discussion of the individual 
charts at the class meeting. These charts were de- 
signed to record the outstanding features of the 
week's history. Gain or loss of weight, number of 
rest periods, mid-session lunches, use of tea and 
coffee, and caloric intake as well as progress in the 
correction of defects, were graphically indicated by 
this means.* 

CLASS INSTRUCTION 

During the first term the several nutrition classes 
met for weekly half hour class sessions in the eye 
clinic room. As several classes of the same grade 
exist in P. S. 64, each of the nutrition groups was 
recruited from children belonging in more than one 
class-room. Thus many members were strangers to 
each other and this fact, together with the unaccus- 
tomed room and special teachers, was partly respon- 
sible for the formality and restraint which char- 
acterized the class sessions at first. The average age 
range was sufficiently limited to make a similar pro- 

* See Appendix C. 



46 HEALTH EDUCATION 

cedure feasible for all the groups with the exception 
of the first grade. For them, however, the type of 
class instruction employed was quite unsuited and 
beyond their ability to comprehend. Though they 
did acquire a conception of the chart and its meaning 
and a few outstanding facts concerning health habits, 
relatively little was accomplished during the term 
toward developing methods better suited to their 
years. At first the conduct of the class devolved on 
the physician, Dr. Emerson at the beginning, and 
later Dr. Henry J. Schreiber who assisted him. The 
individual charts were arranged on the wall facing 
the class, in the order of greatest gain for the week, 
and each child was seated before his own chart. 
Thus the distinction of "head" and "foot'' of the 
class was made prominent, and any mothers pres- 
ent were seated, each behind her own child, with 
the view of further emphasizing the idea of success 
and failure. The subject matter of the lessons was 
chiefly derived from consideration of the individual 
charts, and the conclusions to be drawn from the 
relative gain and loss they indicated. Interpreta- 
tions were supplemented by the nutrition worker's 
notes made at the time of the weekly weight taking. 
There was also discussion of related informational 
matter. Nutritional standards, the significance of 
measured feeding, the value of milk and cereals, the 
bad effects of tea and coffee, food habits and general 
health habits were thus presented to the children's 
attention in their direct bearing on their own phy- 
sical welfare. Special deductions and recommenda- 
tions in regard to individual children resulting from 
this class discussion were noted, and repeated later 



THE INITIAL PROGRAM 47 

to the child or his mother by the nutrition worker. 

It will be evident that little opportunity was 
afforded the physicians for special planning of the 
day's discussion in advance, as they were under the 
necessity of receiving the material for discussion 
from the nutrition worker at the time the class as- 
sembled. Such a situation invariably results in 
much repetition, and relatively little opportunity for 
developing the possibilities of the subject matter. It 
is the usual procedure where the class method has 
been adopted for clinic use, and this first term might 
well be called the "clinic stage" of our class proce- 
dure. The problems arising as well as the techniques 
employed are, we believe, fairly characteristic of the 
usual clinic experience. The limitations disclosed, 
so far as they concern the enlistment of cooperation 
from the children, were inherent in the situation and 
arose first from the unequal physical endowment 
of individuals and consequent inability to accom- 
plish results in direct ratio with effort, secondly 
from the inequality of home facilities for coopera- 
tion which contributed in increasing measure to the 
workers' sense of injustice toward certain children. 
In addition, there was the inaccuracy of home rec- 
ords and the attendant difficulty of exercising proper 
judgment in regard to a child's veracity. Every at- 
tempt on the school's part to secure data from the 
home is more or less subject to this difficulty and 
the possibility of encouraging inaccuracy or even 
conscious deceit is a serious one. 

In addition to these difficulties others arising from 
faulty techniques should be mentioned. The use of | 
competition was certainly questionable in view of the 



48 HEALTH EDUCATION 

fact evident to all, that often conscientious children 
failed to gain as much as others who were careless 
or lacking in interest. The discouragement felt by 
the individual who could not approximate his normal 
weight line, was only increased by the introduction 
of the competitive idea, and the arrangement of the 
charts each week in the order of weight increase with 
the best record at the "head of the class." The 
appeal to future benefits to be secured, as a "place 
on the ball team in high school/' was also employed, 
although generally recognized by the modern school 
of teaching as insufficient for enlisting continued 
cooperation from the average child. 

Half an hour for discussion of the kind involved, 
in a class of 20 to 25, led to hasty and occasionally 
to false deductions as to causes of failure, the injus- 
tice of which was deeply felt by the children con- 
cerned. But the didacticism and formality of the 
class procedure effectually prevented remonstrance 
or explanation in such cases, especially as the center- 
ing of attention on the chart made for self-con- 
sciousness. The impressions of a teacher who 
made a number of visits to the several classes may 
well be quoted here: "The children clearly showed 
self-consciousness; their attitude was a listening 
one ; they seldom had a chance to say anything except 
in reply to direct questions. They were talked to 
rather than with; the latter takes more time, but 
does it not make for a greater feeling of responsi- 
bility, less direct adherence to direction and more 
thinking out, less mere cure and more growth of 
judgment? Moreover, much of the talk is for each 
child a repetition of what the nutrition worker has 



THE INITIAL PROGRAM 



49 



already gone over with him, when she weighed and 
measured him and made his diet list. It must seem 
to him unimportant, except to make him conspicuous, 
with the attention of the doctor and others focussed 
on him. Do we wish him to like this? The social 
element seems unnecessarily left out. Should not 
public discussion be reserved for topics of common 
interest, topics of an interest that is clearly common 
to all of them, something that cannot seem an ex- 
ploitation of individual ailments f After all it is not 
a difference of subject, but of approach. Health 
rather than cure should be the function of a class- 
room talk." 

Statistical Data and Interpretations 

GROUP SELECTION 

Eight hundred children of the four grades selected 
were weighed and measured with the results shown 
in Table I: 



TABLE I* 

Results op Measubements, Children of Four Grades 



Grade 


Grade 


Grade 


Grade 


VII 


VI 


V 


I 


173 


245 


127 


255 


25 


39 


27 


43 


14.4 


15.9 


21.3 


16.9 



Total 



Total number 

7% or more underweight. 
Per cent underweight . . . 



800 

134 

16. 



* The computations of statistical data and charts appearing in this 
chapter and the next were made by Dr. David Mitchell and pub- 
lished in The Pedagogical Seminary, March, 1919 and March, 1920. 
They are reproduced here by courtesy of the editors. 



50 



HEALTH EDUCATION 



At no time was the attempt made to weigh and 
measure the entire school population, as P. S. 64 
enrolls approximately 3000 pupils and from the 
first it was our purpose to work intensively with a 
relatively small number of children. In so far as 
these four grades may be considered to represent a 
cross-section of the school population at the begin- 
ning of our work in February, 1918, the above aver- 
age, 16.8%, approximates the average of children 
7% or more underweight throughout the school at 
that time. 

The children of the Terman and open-air group 
are not included in the above cross-section, as they 
cannot be considered representative of the average 
since they were drawn from two specially selected 
groups. Results of the initial weight-taking in these 
two groups and comparison with the results in the 
regular grades are shown in Table II. 



TABLE II * 

Results op Measurements, Special Classes and Regular 
Grades 





Terman 


Open-air 


Grades 


Total 


Total number 


69 
19 
27.5 


25 

7 

28 


800 
134 
16.8 


894 


7% or more underweight 

Per cent underweight 


160 
17.7 







* For distribution table of the total number weighed see Appen- 
dix A, 



THE INITIAL PROGRAM 



51 



COMPARATIVE RESULTS IN" WEIGHT INCREASE 

Of the total 160 children found 7% or more under- 
weight, 105 were enrolled in nutrition classes. 
Twenty more were included in the group of fifth 
grade boys given the mid-day dinner. The results 
of the experiment in terms of weight increase for 
the several groups after nineteen weeks are given 
in Table III. 



TABLE III * 

Comparative Weight Increase of the Several Groups after 

19 Weeks 



Group 


No. 
Enrolled 


Pounds 
Total 
Gain 


Normal 

Expected 

Gain 


Net 
Gain 


Percentage 

of Normal 

Gain 


7th grade 
6th grade 
1st grade 
Terman 
Open air 

5th grade 


23 
28 
26 
17 
11 

105 

20 


72 
109 
55.7 
61.6 
13.7 

6 


64.8 
89.9 
40.5 
43.2 
23.4 

23.2 


7.2 

18.1 

15.2 

18.4 

- 9.5 

-17.2 


111.1 
120.1 
137.5 
142.6 
59.1 

25.9 



* The estimates of normal expected gain were calculated in the 
accepted way from the average yearly increase as given in the Burk- 
Boas table of normal weights. That is, a proportional increase for 
the period (19 weeks) was estimated on the basis of a supposed 
steady increment in weight from month to month throughout the 
year. Thus if the normal annual increase for a 12 year old boy 
of a certain height is 8 pounds, in nineteen weeks he would be ex- 
pected to gain approximately 3 pounds. In view of subsequent find- 
ings as to seasonal variation in weight increase (see p. 127) it will 
be apparent that the normal expected gain for fractions of a year 
cannot be so simply determined, and that the results in the given 
tables, except for the total number of pounds gained, have been 
seriously undercut. They are included here, however, because they 
still afford a basis for assessing the comparative results obtained in 
the different groups. 



52 



HEALTH EDUCATION 



Comparison of the weight increase for these 
groups with variations in their several programs is 
shown in Table IV. 

TABLE IV* 

Comparison op Variations in the Several Programs and Results 
in Weight Increase 



















Results in 


Group 


Physi- 
cal 
Care 


Instruc- 
tion 


Rest 


Lunch 


Dinner 


Fresh 
Air 


Lighter 
Pro- 
gram 


per- 
centage 
of Normal 
Gain 


Terman 


* 


* 


* 


* 


* 


X 


X 


142.6 


1st grade 


* 


* 


X 


* 


X 


X 


X 


137.5 


6th grade 


* 


* 


* 


* 


* 


X 


X 


121.25 


7th grade 


* 


* 


* 


* 


X 


X 


X 


111.1 


Open air 


* 


* 


* 


* 


X 


* 


* 


51. 


5th grade 


X 


X 


X 


X 


* 


X 


X 


25.9 



(* = Yes. x = No. ) 
INTERPRETATIONS 

While only tentative conclusions are possible 
owing to the small number of individuals in each of 
the groups discussed, certain interpretations can be 
offered in connection with these tables. The most 
striking fact recorded is the apparent failure to 
secure results in weight increase that are directly 
attributable to the school feeding program. From 
Table IV it is evident that some children, to whom 
the mid-day dinner of 1000 calories was served, 
gained considerably less than others in whose pro- 
gram it was not included. While the greatest aver- 
age percentage of gain was made by the Terman 
class who received both mid-day dinner and mid- 
morning lunch, the average gain made by the first 
grade was nearly as great, yet no dinner was at- 
tempted for them. The fifth grade children whose 



THE INITIAL PROGRAM 53 

program was limited entirely to the mid-day dinner, 
show the least satisfactory results, as they lost 
weight steadily through the four months of the 
experiment. 

These results are not surprising in view of the 
problems attending the mid-day dinner. As has 
been already indicated (p. 42) the children were 
afraid of unaccustomed food and used to high sea- 
soning. Thus they did not find the meal appetizing 
and they were not hungry enough to eat what they 
did not like. Had the period of the experiment been 
a longer one, a greater degree of cooperation might 
have been secured from them as a result of the pro- 
gram of instruction. How far the results to weight 
increase would have been augmented, however, re- 
mains a speculation. Aside from demonstrating 
some practical difficulties of a school feeding pro- 
gram, our results for the mid-day dinner are quite 
inconclusive. 

As mid-morning lunches were served to all the 
children with the exception of the fifth grade, we 
must look to other factors for the interpretation of 
the relative gains shown by Table IV. 

The distinguishing feature of the Terman group 
is its intelligence (measured by a special standard) 
and this may be supposed to have made the instruc- 
tion given it more effective. An intelligent over- 
control of the environment by adults is one of the 
goals set by our attempted program. To such an 
over-control the intelligent self-control of the Ter- 
man group might be said to approximate. The 
eager-minded and participatory attitude of these 
children toward all their school activities, ensured 



54 HEALTH EDUCATION 

better cooperation on their part than conld be ob- 
tained from children of the regular grades. Thus 
intelligence in the group, or in direct application to 
the control of the group, is suggested as one ex- 
planation of the satisfactory results they achieved. 
It is also probable that as a group the chief causal 
factors of their underweight were of a nature cal- 
culated to permit ready response to an improved 
regime. It is quite possible that the Terman children 
were underweight largely because of an increased 
metabolism, and that their ability to respond to im- 
proved conditions of food taking, rest and fresh air 
was therefore proportionately better than that of 
individuals in the other groups.* 

Second only to the gain made by the Terman class 
is the record of the first grade children, yet their pro- 
gram included only the provisions for physical care 
and instruction and was considered by members of 
the staff the least satisfactory of any afforded. 
Because the program of instruction was ill-adapted 
to their age period, increased necessity for co- 
operation from the home was felt by the staff, and 
therefore much greater effort was made to interest 
the mothers and secure their attendance at the class 
sessions. Our efforts were reinforced by the greater 
readiness of parents to maintain intelligent control 
and lend cooperation to special efforts on behalf of 
young children. Thus better environmental control 
was secured for this group than we were able to 
secure for the others, and the special factor of in- 

* See Burnham, Wm. EL, The Metabolism of Childhood, Pedagogical 
Seminary, Dec, 1920, pp. 304-322. Where the hypothesis is pre- 
sented that the curve of learning is correlated with the curve of 
metabolism. 



THE INITIAL PROGRAM 55 

telligence in the Terman group was paralleled, in 
the case of the first grade, by the factor of adult 
supervision. In addition, we must consider too, the 
readier response of little children to conditions 
affecting them for good or ill. This better ability 
of their age period to respond, again parallels the 
probable better ability to respond on the part of the 
Terman group. 

Intelligent control of the environment was less 
easily secured for the children of the sixth and sev- 
enth grades. It was not only more difficult to secure 
cooperation from the homes but, with children of 
their age, home cooperation was less effective, as 
many of them were quite beyond parental control. 
Moreover, it was far more difficult to enlist their own 
cooperation. This was especially true of the seventh 
grade in which there were a number of over-age 
boys, who had lost all interest in school activities, 
and were merely marking time, and waiting to take 
out their working papers. These big fellows consti- 
tuted an unruly element, and to a certain extent were 
leaders because of their years and daring. Obvi- 
ously, their level of intelligence was inferior. Their 
cooperation was never successfully enlisted. The 
nutrition program was regarded by them as "baby- 
ish," and the difficulties in discipline experienced in 
the lunch room and during the rest period emanated 
for the most part from them. The sixth grade group 
had also its quota of retarded boys, but they were 
proportionately fewer and the greater differences 
in physiological age existing between them and the 
younger members of their class rendered their influ- 
ence less disturbing. The comparative results ob- 



56 HEALTH EDUCATION 

tained in these two groups, 120% for the sixth grade 
group and 111% for the seventh grade, seem to de- 
pend in the main on this factor of their personnel. 

The failure of the fifth grade to make gains is 
easily explained in view of the circumstances sur- 
rounding the mid-day dinner, and the additional fact 
that no attempt to enlist their cooperation by a pro- 
gram of instruction was made. It will be noted 
(Table I) that this grade showed the largest num- 
ber of underweights and as individuals they may 
have represented more serious problems of malnu- 
trition or of physical defect than did the other 
classes.* In addition, the age period of the average 
fifth grade boy offers a possible contributing cause. 
(See p. 23.) The only fact established by their place 
in the experiment is the failure of the school lunch 
to compete with a more comprehensive program. 

Like the fifth grade, the open-air group of this 
first year cannot be considered comparable to the 
others. It undoubtedly included incipient cases of 
disease and its members were probably candidates 
for a far more controlled regime than could be sup- 
plied through the school procedure. As it seemed 
impractical to send the members of this group to the 
eye clinic, class instruction was given them in 
their own room. As the rest of the class did not 
share in this, there was always a consciousness 
among them that they were on a different basis from 
the others, and a resulting lack of cooperation was 
probably a factor in their poor record. 

Although the program of school feeding plays no 

* No physical examinations were made or social histories taken for 
this group. After the initial height and weight taking they were 
merely given the mid-day dinner. 



THE INITIAL PROGRAM 



57 



part in our interpretation of relative gains made by 
the several groups, there can be little doubt that the 
actual gains made by the Terman, sixth, seventh, 
and first grade classes were due in considerable 
part to the mid-morning luncheons. It is also 
probable that the mid-day dinner afforded some re- 
sults for the Terman group, because of probable 
better and more intelligent cooperation on their part 
in this, as in other features of the program. 

PHYSICAL DEFECTS 

N aso-pJiaryngeal Obstructions. — A comparison of 
the 49 children who were recommended for tonsil 
and adenoid operation and failed to secure treat- 
ment, with the 32 children who were free from such 
defects appears in Table V. As the groups were not 
of equal size the percentages best indicate the rela- 
tive results. 

TABLE V 

Comparative Gains of Children without Naso-Pahryngeal 

Obstructions and Those Recommended for Operation 





With 
Obstructions 


Without 
Obstructions 




No. 


Per Cent 


No. 


Per Cent 


Lost weight 


4 
18 

24 

3 


8.2 
36.7 

49 

6.1 


1 
9 

12 

10 


3.1 


Gained less than normal 

Gained more than normal, 1 to 
100% 


28.1 
37 


Gained more than normal, over 
100% 


31.3 








49 


100 


32 


100 



From this table it is evident that 55.1% of the 
children from whom these defects were not removed 



58 



HEALTH EDUCATION 



made gains in excess of normal while 68.8% of the 
children without such defects gained in excess of 
normal. The relative amount of gain must be noted, 
however, and the record of gains showing over 100% 
in excess of normal is only 6.1% for children having 
defects as against 31.3% for those without defects. 
A study of the gains made by 19 * of the cases 
operated for a period of five weeks before and 
five weeks after the operation is given in Table VI. 
In practically every case the child lost weight at the 
time of the operation and recovered it in about a 
week. The five-week periods are therefore separated 
in each case by a few intervening days in which this 
recovery was taking place. 



TABLE VI 

Per Cent Gain op 19 Children for Period of Five Weeks before 
and Five Weeks after Tonsil and Adenoid Operation 



No. 


Before 


After 


No. 


Before 


After 


1 


2.4 


1.4 


11 


-1.3 


2.5 


2 


3.6 


8.2 


12 


1.1 


3.3 


3 


1.7 


1.0 


13 


0.6 


1.9 


4 


0.5 


5.6 


14 


-0.9 


3.4 


5 


-0.3 


1.5 


15 


3.3 


4.6 


6 


-1.3 


3.4 


16 


5.8 


-1.3 


7 


0.6 


2.5 


17 


0.9 


4.0 


8 


-2.8 


5.8 


18 


-0.3 


4.7 


9 


2.8 


3.9 


19 


-1.7 


1.5 


10 


0.9 


6.4 









Carious Teeth. — Of the entire group 88 were ex- 
amined for dental caries and 63 were found to have 

* One child of the 20 operated is not included owing to an attack 
of influenza following his operation. 



THE INITIAL PROGRAM 



59 



from 1 to 12 carious teeth. An attempt was made 
to correlate this defect with the degree of under- 
weight found, but this was unsuccessful. The re- 
sults of the study are given in Table VII. 

TABLE VII 

Comparison of Dental Caries and Average Percentage 
Underweight 



No. of Carious Teeth 


No 
Record 





1 


2 


3 


4 


5 


6 


7 


8 


9 


10 


11 


12 


No. of children 


17 


25 


21 


12 


9 


8 


3 


3 


2 


2 


1 


1 





1 


Average per cent un- 
































10 


10 


9 


8 


13 


9 


10 


10 


16 


10 


13 


9 





13 



Summary 

At the end of the first school term no spectacular 
gains had been made by the children enrolled in our 
nutrition classes. On the contrary, progress had 
been slow and discouraging. The results achieved 
in "percentage of normal gain" fell far short of 
our attempted goal, and of the entire number en- 
rolled (105) only two had "graduated" by reaching 
the standard weight for their height and age. 

In the light of subsequent experience these results 
appear less disappointing and we can appreciate to- 
day that the standards used in making our evalua- 
tions were too high, as they were based on an "ex- 
pected gain" in the determination of which no allow- 
ance for the factor of seasonal variation had been 
made. Not until two years later did our staff become 
aware of the importance of this seasonal factor and 
of its effect on previously accepted standards. But 
the complexity of our problem, and of the underlying 



60 HEALTH EDUCATION 

causes and contributing factors of malnutrition had 
been pretty well revealed to us by June of the first 
year. 

The outstanding facts of the first five months ' 
experience may be briefly stated as follows: The 
wide variations in response shown by the individual 
records had emphasized the importance of the child's 
physical status and home conditions in determining 
results. At the same time the relative gains of the 
several classes had brought into relief the depend- 
ence of success on the child's own cooperation and 
the necessity of better techniques for enlisting it. 
In comparison with these essential factors the dif- 
ferences in the various programs arranged were 
shown to be negligible. Better cooperation from the 
home, better progress in the correction of defects, 
more careful physical examination and diagnosis 
and a better class procedure were felt to be neces- 
sary lines of development, if we were to cope suc- 
cessfully with the problems involved. 

Certain limitations, too, were apparent in the 
chart forms and other records used during the first 
term. These had been copied from those in use at 
the Massachusetts General Hospital and were better 
adapted to gathering the type of material needed for 
purposes of clinical diagnosis than for collecting 
data for statistical treatment.* As a result of our 
experience in the first term 's work we developed an 

*For similar difficulties experienced with physical examination 
records see Dewey, Child and Euml, op. cit., p. 160, and Heron, The 
Influence of Defective Physique and Unfavorable Home Environment 
on the Intelligence of Children, Galton Laboratory Memoirs VIII. 
1910. 



THE INITIAL PROGRAM 61 

individual record blank resembling in some re- 
spects that used by the visiting teachers of the city. 
The weight chart was somewhat modified as well 
to suit our particular needs.* 

* See Appendix B and C. 



CHAPTER IV 

DEVELOPMENT OF PROCEDURE— GRAMMAR 
GRADES— SEPTEMBER, 1918— JUNE, 1919 

Basis of Reorganization 

In organizing the classes for the second year, an 
attempt was made to develop our program in direc- 
tions calculated to secure better control of the envi- 
ronment and added opportunities for enlisting the 
children's cooperation, since the experience of the 
first year had emphasized the importance of these 
factors in securing weight increase. As no convinc- 
ing results in favor of the mid-day dinner had been 
afforded, it was decided to give up this feature of 
the experiment and to work more intensively along 
other lines. The work of the New York School 
Lunch Committee had been discontinued at the end 
of the previous term and their cooperation was no 
longer available. Without their aid an attempt to 
secure a hearty meal at school for any of our classes 
presented many difficulties beyond the increased ex- 
penditure of money and service involved. Dr. 
Emerson's belief, that such a meal though advan- 
tageous is not necessary to the success of the nutri- 
tion class program, was an influential factor in reach- 
ing the decision to discontinue it, especially since his 
opinion appeared to be confirmed by our data. 

62 




PQ 



Ph 



DEVELOPMENT OF PROCEDURE 63 

Viewed in the light of our subsequent experience 
and with the statistics for three consecutive years 
available, the decision to discard entirely so im- 
portant a feature of the program at so early a 
stage of the experiment now appears question- 
able. More serious, however, was the basis on 
which the new classes in the fall of 1918 were 
organized. Not one of these will be found strictly 
comparable to any of the groups organized in 
the previous year. Thus the advantages to be 
gained by continuing to set up really comparable 
groups within a single experiment, and at the same 
time incorporating new features of treatment, were 
largely lost at P. S. 64, and the statistics gathered 
in the three successive years hardly lend themselves 
for purposes of comparison. Two types of influence 
were responsible for the changes which so seriously 
affected our program of research: on the one hand 
the advisability of conforming to the practical situ- 
ation and modifying plans in accordance with ad- 
ministrative and financial considerations, on the 
other the temptation to sacrifice the statistical re- 
quirements for possible benefits to the individual 
child. The organization of the classes in the fall of 
1918 exhibits the latter influence very clearly. Any 
such undertaking as ours must inevitably experience 
the pressure of influences in these two directions, and 
workers should realize that so far as they find it 
inadvisable to carry out a consistent program on the 
basis of verifying and expanding previous experi- 
ence and accumulating comparable data, the possi- 
bilities for much-needed research are endangered. 



64 HEALTH EDUCATION 

GROUP SELECTION 

From the viewpoint of benefit to the individual 
our first need in the fall of 1918 appeared to be pro- 
vision for those children who had been in our classes 
the year before and were still underweight. With 
a view to securing the best environmental conditions 
available for them Dr. Louis Marks, the Principal 
of P. S. 64, arranged for two open-air classes, one 
for sixth and seventh grade children, the other for 
those of the fourth and fifth grades. In these were 
enrolled members of the nutrition groups from the 
fifth, sixth and seventh grade and open-air classes 
of the previous year. To these were added a number 
of boys from the same grades, selected at the open- 
ing of school as conspicuously underweight. There 
were also a few pre-tubercular cases for whom the 
school had to provide open-air facilities. Thus the 
two open-air classes presented the special problems 
of a higher average underweight, and a more or less 
chronic condition of malnutrition, as shown by fail- 
ure to respond to previous treatment. 

A third class was recruited entirely from fifth 
grade boys whose average condition as to under- 
weight was not serious. This group was selected 
with a view to developing an educational procedure 
under usual class conditions, and determining how 
far the borderline and low percentile cases would 
respond to such a procedure. It was hoped results 
would show that by making special provision for the 
more serious cases, a school could secure satisfactory 
results for the majority of its underweight children, 
through further development and adaptation of the 
nutrition class program to typical school conditions. 



DEVELOPMENT OF PROCEDURE 65 

The choice of fifth grade children for this ex- 
perimental group was determined partly by the un- 
satisfactory showing of the fifth grade in the pre- 
vious year, partly by considerations of administra- 
tive convenience. 

ADMINISTBATIVE ADJUSTMENT 

Dr. Marks' decision to form entire classes of un- 
derweight children was a distinct gain to our pro- 
cedure, as it made possible the development of an 
esprit de corps among the class members that was 
impossible as long as they were distributed amon£ 
the different classes of their grade, and assembled 
only for the weekly sessions in the eye clinic room. 
Class instruction for the open-air groups was of 
necessity given in their own class-rooms, and at mid- 
year the same plan was adopted for the fifth grade 
boys. Thus the eye clinic came to be used only 
for measurements, examinations and individual in- 
terviews. The conduct of the weekly class sessions 
was given to the two nutrition workers who now as- 
sumed this responsibility in addition to their pre- 
vious duties.* 

Physical Care 

This change made for efficiency in the program of 
physical care, as the physician's time could now be 
devoted entirely to the physical examinations and 
diagnosis, and to individual interviews, when it 
seemed necessary to true up the findings of the nutri- 
tion worker or give special advice. The added au- 

* The subsequent developments in teaching methods, and techniques 
for better enlistment of cooperation from the children and from the 
homes, were made under the direction of Miss Harriet A. Forbes. 



66 HEALTH EDUCATION 

thority of any recommendation from the doctor was 
always evident and could be relied on for securing 
additional emphasis when necessary. 

Results obtained in the correction of defects 
showed an appreciable gain over those of the first 
year.* Tonsil and adenoid cases were treated at the 
Metropolitan Hospital. The treatment of dental 
caries was continued conscientiously but progressed 
slowly owing to the inadequate provision of clinics 
for the purpose. Had it not been for the interest 
and kindness of a skillful and busy dentist in prac- 
tice, Dr. H. A. Koonz, who treated many of our 
children without a fee, it would have been impossible 
to secure dental treatment for them. 

Cooperation of the Home 

In spite of the failure of parents to attend the 
class meetings of the previous year, we continued to 
urge them to be present in the belief that our work 
would gradually enlist interest and better coopera- 
tion, as the individual families and the community 
at large became more fully aware of its significance. 
Our attempts to secure their attendance continued 
all through the second year of the experiment, but 
as time wore on and our realization of the need of 
home cooperation increased, we were led to increase 
the number of home visits considerably. The better 
to enlist the mother's interest a miniature copy of 
the child's weight chart was taken by the nutrition 
worker on these visits and carefully explained 
to her. 

Frequently during such a visit the nutrition 

* See p. 87 (gtatistical data) . 



DEVELOPMENT OF PROCEDURE 67 

worker was able to persuade the mother to prepare 
cereal and to serve smaller portions when trying to 
establish the habit of eating more nourishing food; 
or she was encouraged to make greater effort to pre- 
vent late hours, and in various other ways to give her 
aid to the experiment. Almost invariably we found 
her keenly interested in her boy's health, and fre- 
quently the cooperation given was invaluable. A spe- 
cial problem of the nutrition class program is the 
difficulty of assessing the accuracy of the children's 
statements concerning their home regime. Facts 
gathered during the home visits served as a check 
on the child's reports as to his habits and were used 
to corroborate them or the reverse. Where testi- 
mony was conflicting, that bearing the best indica- 
tion of good faith and accuracy was taken. 

Fifth Grade Class 

ENVIRONMENT 

Except in the extreme winter weather the windows 
of the fifth grade room were kept open. The boys 
wore their outdoor sweaters and coats, and enjoyed 
the fresh air. Rest periods were arranged during 
the morning session, the children remaining seated 
with arms and heads on the desks before them. In- 
struction in relaxation was given in connection with 
these attempts at conserving energy, and a certain 
success was achieved, though with boys of this age 
the problem was difficult, and five minutes of real 
relaxation was almost as much as could be secured 
in a fifteen minute period. The children were urged 
to bring mid-morning lunches from home and a reg- 
ular time was arranged for eating them. The at- 



68 HEALTH EDUCATION 

tempt to secure home cooperation in the provision of 
these lunches was never more than partially success- 
ful. Failure to supply them was frequent, and those 
brought averaged much below the caloric value pre- 
scribed (250-300 calories). Often a small apple or 
an unappetizing roll would be their only constituent. 

MOTIVATION 

Every effort was made to enlist a spirit of coop- 
eration among the children sufficient to ensure the 
carrying out of the health program at home. As has 
been stated, the change in class organization was a 
gain in this respect, and a further advantage resulted 
from the decision reached at mid-year, to hold the 
class instruction sessions in the regular class-room 
instead of the eye clinic room. The familiarity of 
the surroundings, better acquaintance between the 
members of the class and the presence of the class 
teacher, the resulting informality and closer identi- 
fication of the procedure with usual school interests 
and attitudes, all contributed to establishing a class 
spirit. The idea of competition between individual 
members of the class was dropped, and children were 
urged to exceed their own previous record instead. 
A significant change, too, was made in the chart 
where the normal weight line was supplemented by 
the "line of expected gain" for the individual, the 
two together forming a zone within which progress 
could be considered achievement.* By this device 
some discouragement on the part of those who could 
not approximate the standard of normal weight for 
height was avoided. At the same time the use of 

* See Appendix C. 



DEVELOPMENT OF PROCEDURE 69 

the colored markers in connection with the charts 
became more evidently one of records rather than 
rewards. The familiarity of the nutrition worker 
with the weekly records, and the facts of home en- 
vironment and individual history, made possible 
more careful interpretation of the charts, at the 
same time that discussion of them was made briefer 
and more impersonal. 

These changes in class-room technique made for 
increased effectiveness in securing the cooperation of 
the children. An additional stimulus was furnished 
by giving the boys some realization of the meaning 
of the class as an experiment. They were interested 
to feel themselves part of a serious investigation of 
the means by which the percentage of underweight 
in their school could be reduced. That they really 
grasped something of their own place in the experi- 
ment and of its social significance, was evidenced 
by the increased care with which they made their 
weekly reports as this conception became clearer. 
The question may well be raised how far such a 
special appeal can be regarded as legitimate in an 
educational experiment. Certainly any successful 
results obtained are less convincing for a general 
program because of its use. Whatever response may 
be secured from an individual group by keeping 
before them the fact that they are pioneers, and that 
the future of others depends on their record of suc- 
cess or failure, the necessity of securing no less 
active cooperation from succeeding classes must be 
kept in mind. 

The work was started late in November. By mid- 
January an attitude of habitual participation and 



70 HEALTH EDUCATION 

ease of manner during discussions was manifest, 
and there was no sign of the self -consciousness noted 
the previous year nor of the clinical atmosphere. 

SUBJECT MATTER. 

If the teaching of the nutrition workers was less 
authoritative than that of the physicians, it was also 
less didactic and more stimulating to the child's own 
thinking. An aim kept constantly in view was to 
lead discussion away from the individual records 
and consideration of the charts, to topics emphasiz- 
ing health and constructive suggestions for living 
habits, not only for the class but for their families 
and the community. This resulted in the develop- 
ment of a considerable program of subject matter 
which proved full of interest for the children. The 
content involved is shown in the following summary, 
derived from the class discussions for a period of 
28 weeks. Subjects were reviewed repeatedly with 
no apparent loss of interest, and a new fact was re- 
ceived with absorbed attention by the majority of* 
the class. 

Correct weighing and care of scales. 

The nature of an experiment — its social value — the scientific atti- 
tude of mind. 

What constitutes good nutrition. 
The calorie — a unit of heat. 
The uses of food: 

As fuel — for heating the body. 

As fuel — for maintaining the internal activities (respiration, cir- 
culation, etc.). 

As fuel — to produce energy for all kinds of work and play. 

As fuel — for reserve energy, storage for emergency uses. 

For repair. 
The significance of measured feeding. 



DEVELOPMENT OF PROCEDURE 71 

The value of certain foods — milk, cereals, vegetables, fruits, meat, 
eggs. 

The nature of habit formation. 

Food habits. 

Other factors in promoting good nutrition — fresh air, rest, exercise. 

Prevention and treatment of physical defects. 

Care of the teeth. 

Effect of tonsil and adenoid obstructions. 

Eye strain. 

It took several weeks for the children to get a 
working knowledge of caloric values, and to under- 
stand not only the term but the significance of the 
body's fuel needs. The dramatic story of the college 
boys whose willing immolation in the calorimeter 
made them heroes in the minds of the class, was used 
as the starting point of this interest. The idea of 
measured feeding followed naturally, with the con- 
ception of food as fuel and a source of energy for the 
human machine. The need to regulate the supply as 
the engineer does for his monster of iron and steel 
was also evident. Then followed special uses of dif- 
ferent foods and the relative values of those found 
in their own dietaries or available for them. Wax 
models showing 100 calorie portions of suitable 
breakfast dishes were secured, to assist in the inter- 
pretation of caloric values in terms of daily experi- 
ence, and to demonstrate a few menus for the ideal 
breakfast. On one occasion several children from 
the open-air classes were taken for a trip to the 
Post-Graduate Hospital, where a very complete ex- 
hibit of this kind is to be seen, with a view to 
helping them estimate more accurately the caloric 
value of the food portions served them at home. 
Samples of real food were occasionally used in 



72 HEALTH EDUCATION 

conjunction with the wax models for this type 
of illustration. Mention was made of acquiring 
proper food habits, and at one lesson a psychologist 
was present, and explained habit formation to the 
class. This talk was frequently referred to by the 
children afterwards. Incidentally, some important 
conceptions of the value and interest of work done 
in the scientific spirit, and of the exactness required 
in carrying out the details of scientific work were 
gained. In the study of pure milk, for example, each 
child could get a picture of the interrelationship of 
the processes involved in getting milk from farm to 
child consumer, and could feel the disastrous effect 
of failure on the part of any individual to perform 
his part conscientiously. Their interest in facts and 
changes recorded on charts other than their own was 
indicative of this budding scientific spirit, and as the 
year progressed the class discussions increasingly 
reflected it. The boys would gather around the 
charts eagerly talking about the gains and losses in 
a surprisingly impersonal tone. The assertion of 
a boy on one occasion, "When I drink milk I don't 
gain ; when I drink coffee I do, " was met by a chorus 
of exclamations and demands for an explanation. 
During a discussion of the plan to give a demon- 
stration in the auditorium, one boy volunteered the 
suggestion that all charts should be shown whether 
good or bad. This was talked over pro and con as 
to its usefulness, and no one suggested that his chart 
should be omitted. 

This auditorium program took place late in the 
year and was arranged by the class at the sugges- 
tion of the principal. It was sufficiently successful 



DEVELOPMENT OF PROCEDURE 73 

to bring a request from the teachers that a regular 
auditorium period be taken over by the nutrition 
classes. The wax food models were shown and ex- 
plained by the boys, as well as several of the weight 
charts, two from the fifth grade, and two from each 
of the open-air classes. The boys who had secured 
treatment for physical defects then marched on the 
stage in two groups, and a spokesman explained 
what they had done to become better fit. 

The few stories introduced in the class work were 
true ones. Interest in Roosevelt and his determina- 
tion to overcome his weakness of body was keen, and 
Horace Fletcher, with his ideas about eating, was 
well received. On several occasions a visitor re- 
corded portions of the class discussion to which she 
listened, and the following quotations from her note 
book are of interest in connection with the problem 
of home environment : ' ' My baby leaves out his milk, 
but now I make him drink it. ' ' " My sister goes to 
bed earlier. " " My big brother didn't believe in eat- 
ing slowly, but he tried it and he gained." "Now 
I get my brother and sister to eat the same things." 

In the month of May the boys were asked to write 
compositions on the value of the Nutrition Class and 
urged to tell exactly what they thought of it, "for 
and against. ' ' About one-half of the 33 papers were 
against the class, largely because of the "bother of 
tonsil operations." Rest was also referred to many 
times as perhaps the greatest "bother" of all, re- 
quiring much self-control and resolution to put 
through. The compositions in general are note- 
worthy for their sincerity and freedom of speech, in 
decided contrast to what is usual in the class-room. 



74 HEALTH EDUCATION 

Even where disapproval is expressed, as in the fol- 
lowing excerpt, we can realize that the writer had 
gained something from the experience: "I like to 
go to bed late and I like to eat fast. I don't like 
the idea of the calories. The nutrition class is good 
for those who like it." A more submissive spirit 
tells us: "I used to take a roll and run out in the 
street and play. Now I learned to eat a roll and sit 
down by a table and have more a joyable time." The 
following quotation shows the common attitude of 
the boys when they were in the class-room: "I am in 
the nutrition class and I think I am here long enough 
to know whether it has helped me or not. When I 
was not in the nutrition class I did not know that I 
ought not to drink tea or coffee. I know enough to 
go to sleep early and try to take rest periods or lunch 
periods and know nearly everything that will make 
me gain." 

ESTIMATE OF METHODS 

It will be recalled that the program developed for 
this group was undertaken to determine how far 
results could be secured from the nutrition class 
under typical school conditions. For this reason the 
type of class instruction used presents several fea- 
tures for special consideration, and well illustrates 
the possibilities and limitations of health teaching 
under the conditions imposed. It will be evident 
that the socialized recitations with their appeal to 
group psychology, effectively secured the interest of 
the children, whose enjoyment of the weekly discus- 
sions, and increased facility of expression and ease 
of manner as the year progressed, were noted 



DEVELOPMENT OF PROCEDURE 75 

by all who observed them. Partly because of 
these conditions, partly because of the natural 
interest nearly all children feel for the subject 
matter covered, it was possible to present it 
always in its scientific aspect and from the 
1 'work level" approach. The class instruction 
used will be recognized as the best of its kind 
and, as an informational procedure, was highly suc- 
cessful. The subsequent record of the children 
affords evidence that it was fairly successful also, 
in establishing a creative attitude on their part 
toward the problem of health. As a weight-getting 
and habit-forming program, however, it undoubt- 
edly left much to be desired, and in this respect its 
limitations were the limitations incident to the usual 
public school environment, when equipment and fa- 
cilities for radical readjustment of existing condi- 
tions are not provided. We may well ask ourselves 
what might have been the results in weight increase, 
had mid-session luncheons or a mid-day dinner and 
rest facilities, similar to those provided for groups 
in the previous year, been arranged for these chil- 
dren, whose cooperation and interest had been so 
effectively appealed to, and the causal factors of 
whose underweight were, for the most part, of a less 
serious nature than in the case of other groups con- 
sidered. 

Open-Air Classes 

ENVIRONMENT 

The open-air classes throughout the school system 
are designed to provide special conditions to meet the 
needs of children handicapped because of tubercular 



76 HEALTH EDUCATION 

diathesis, anaemia or serious malnutrition. Children 
suffering from various other maladies of a nature 
which does not exclude them from school, easily drift 
into these classes, so that in the minds of many chil- 
dren they have become identified with the idea of 
sickness and ill-health and to a certain degree carry 
a resulting stigma. 

As existing in P. S. 64 they presented the follow- 
ing points of distinction from the rest of the school : 
a sunny room with windows adjusted in order to 
swing and be open the year around, army cots with 
blankets or sleeping bags for daily rest periods, 
movable desks and chairs, mid-morning luncheon, 
a bonus for the teacher in order to secure a woman 
with special social and technical qualifications. With 
such a modification of the school environment, and 
with health rather than school progress the goal 
before the class, there is an inevitable slowing down 
of the usual speed in class-room procedure, with a 
consequent gain in informality, all of which is obvi- 
ously of benefit to the child, and in close accord with 
the ideal program for the nutrition class. In the 
two rooms placed at our disposal, therefore, Ave had 
only to make use of features already existing, the 
daily rest period with the children lying flat on the 
back for three-quarters of an hour, sleeping when 
possible, but always remaining quiet in a recumbent 
position, and the mid-morning lunch which was 
served in the class-room. In the open-air rooms the 
need of extra nourishment, especially in winter 
weather, is always recognized, and lunches for them 
have been regularly supplied at P. S. 64 through 
outside subscription. 



DEVELOPMENT OF PROCEDURE 77 

During the coldest weather oatmeal or farina with 
milk was served and taken generally with relish, 
although appetites for the most part needed tempt- 
ing in these particular groups, and it was found 
necessary to vary the luncheon as circumstances per- 
mitted. Hot cocoa was sometimes substituted for 
the cereal and milk. The cooking was done by one 
of the teachers on a small gas stove in the teachers' 
lunch room; and a fireless cooker was available, 
thanks to the teacher of one class, who had been suf- 
ficiently energetic to have it made by one of the 
boys in the school shop. In warm weather a good 
grade of bottled milk was served, also bread and 
jelly sandwiches, or bread and jam. 

With the facilities at her disposal the serving of 
even these simple lunches was something of an 
achievement for the class teacher Any educational 
possibilities incident to the selection, purchase, and 
preparation of them could not be made available for 
the children under the circumstances. The actual 
serving and eating, however, presented opportunity 
for a certain training in food habits, and for discus- 
sion of caloric intake and food values, while the 
group example doubtless played its part in helping 
individuals to cultivate a taste for milk and cereals. 

INSTEUCTION 

The open-air groups offered less opportunity for 
the development of class discussions and subject 
matter content, because of the shorter lesson periods 
arranged for them. A special feature used by the 
nutrition worker in these classes was a small indi- 
vidual chart which the child himself prepared at his 



78 HEALTH EDUCATION 

desk and took home with him, being thus enabled 
to discuss his record with his family from week to 
week. 

A unique use of stories was made by this worker, 
who finding the boys in the lower class familiar with 
and fond of some of the wonder book tales, retold 
The Golden Touch and the story of Penelope, the 
boys making their own applications, in the case of 
Midas sufficiently evident. Penelope, who unravelled 
at night the work of every day, was compared td 
those children who undid the benefits of fresh air 
during their school day by sleeping with closed win- 
dows at night. 

Statistical Data and Interpretations 

GBOUP SELECTION" 

Open-Air Classes. — Of the 48 children enrolled in 
the open-air classes, 29 had been carried over from 
the nutrition classes of the previous year for failure 
to respond to treatment. Of this number 12 presented 
special problems and, although they were seriously 
underweight, no satisfactory diagnosis of the causes 
for their condition was made in the two years they 
remained under our care, nor did they make gains 
in spite of their own sincere efforts at cooperation, 
the enlistment of their parents ' interest, and the best 
efforts of our staff. Sixteen of the class, one-third 
of the total enrollment, were pre-tubercular cases 
and, while a number of these were not seriously 
underweight, they contributed their quota to the 
difficulties of securing gains. The remaining mem- 
bers had been enrolled because they were conspicu- 
ously underweight. Table VIII shows the distribution 



DEVELOPMENT OF PROCEDURE 



79 



of percentages underweight for these groups at the 
initial weighing in September, and again at the final 
weighing in June. It will be seen that just half of 
them were seriously underweight, above 11% for 
height, and only 13 of the 48 were low percentile 
cases. The results at the final weighing show a slight 
approximation to normal. 



Open-air Classes: 



TABLE VIII 
Distribution of Percentages Underweight 
at Different Dates 





First Weighing 


Final Weighing 


- 3 

- 5 


- 5 

- 7 




5 
2 


- 7 


- 9 


13 


7 


- 9 
-11 


-11 

-13 


11 
6 


11 

8 
7 
5 


-13 
-15 


-15 
-17 


10 
3 


-17 


-19 


2 


2 


-19 


-21 


3 


1 




48 


48 



Fifth Grade Classes. — Five classes of fifth grade 
boys, 223 pupils in all, were weighed and measured 
and of the total number 74, or 23.19% were found 7% 
or more underweight. Of this number 13 were 
placed in the lower open-air group, and 39 were 
enrolled in the fifth grade nutrition class, measure- 
ments being taken with indoor clothing and without 
shoes. Owing to various delays, the Liberty Loan 
drive in which the older children were active, and 
the epidemic of Spanish influenza, which disorgan- 



80 



HEALTH EDUCATION 



ized the schools for a period, this class did not begin 
its sessions until nearly seven weeks after the initial 
weighing, when it was found that 22 of the number 
were no longer 7% underweight. Table IX gives 
the distribution of their percentages underweight at 
the initial weighing in the latter part of September, 
and again at the first class meeting in November 
when, as may be seen, 12 individuals were found to 
be between 5 and 7% underweight and 10 more were 
from 1 to 5% underweight. 



Fifth Grade Class: 



TABLE IX 

Distribution of Percentages Underweight 
at Different Dates 



Percentages 


First Weighing 


First Class 


Final Weighing 


3 1 






1 


1-1 








- 1 - 3 




1 


1 


- 3 - 5 




9 




- 5 - 7 




12 


2 


- 7 - 9 


19 


8 


8 


- 9 -11 


11 


4 


5 


-11 -13 


4 


' 1 


6 


-13 -15 


4 


2 


7 


-15 -17 




1 


6 


-17 -19 


1 


1 


5 


-19 -21 






2 


Total 


39 


39 


43 



These unexpected graduates afforded the spec- 
tacular element in the year's record. It will be re- 
called that of the total enrollment (105) in the pre- 
vious Spring, only two were "graduated" in the 
course of 19 weeks of serious effort to provide a 



DEVELOPMENT OF PROCEDURE 81 

corrective program. Now by contrast, we had 22 
ready to "graduate" from a group of only 39 after 
a term of seven weeks and before any program of 
care or instruction had been begun. Not until the 
publication, eighteen months later, of Dr. Porter's * 
statistics on seasonal variation was a satisfactory 
interpretation offered. For although the fall has 
long been recognized as the probable season of maxi- 
mal weight increase, no previous study has shown 
how large a percentage of the total annual incre- 
ment is involved in such variation. In the light of 
Dr. Porter's investigation our spectacular feature 
appears easily accounted for. Heavier under-cloth- 
ing at the second weighing in November probably 
proved a contributing factor, but it is not sufficient 
of itself to provide an explanation. 

Since it was impractical to reorganize the class, 
all school arrangements for the term having been 
made, and the usual school program being more or 
less seriously delayed already by the unusual con- 
ditions attending the influenza epidemic, these 22 
children remained in the class. The final approxi- 
mation to normal weight and its distribution is 
shown in the last column of Table IX. Here the 
effect of Dr. Porter's season of minimal weight in- 
crease seems as apparent as that of the season of 
maximal increase in the results for the period of the 
first seven weeks. Less spectacular perhaps, it 
proved far more disconcerting to the workers con- 
ducting the experiment. Comparing the first weigh- 
ing with the final weighing, the cases are found to 

* Porter, Wm. T., Seasonal Variation in the Growth of Boston 
School Children, American Journal of Physiology, May, 1920. 



82 



HEALTH EDUCATION 



be more uniformly distributed but no decided ap- 
proach to normal is shown. 

Control Group. — 

A Control Group of 35 children who were approx- 
imately of average weight for their height was 
selected at the time of the first weighing, with a view 
to studying the variability exhibited by normal chil- 
dren, for the light it might throw on problems of 



Control Group: 



TABLE X 

Distribution op Weight Percentages at 
Different Dates 



Percentages 


First Weighing 


Second Weighing 


Third Weighing 


12 




1 




11 








10 








9 




1 




8 




1 




7 




1 




6 




4 




5 




2 


1 


4 




1 


1 


3 


4 


3 


2 


2 


3 


3 


4 


1 


4 


4 







6 


5 


6 


-1 


4 


3 


3 


-2 


7 


1 


3 


-3 


7 


3 




-4 






1 


-5 




1 


1 


-6 






3 


-7 




. . 


1 


-8 






1 


-9 




1 






35 


35 


27 



DEVELOPMENT OF PROCEDURE 83 

underweight, especially in regard to the discrimina- 
tion of temporary and chronic cases. A study of 
mental ability in underweight children which formed 
part of our program demanded similar data derived 
from well-nourished children for purposes of com- 
parison. Table X shows the results of the measure- 
ments for this group taken in the fall, in February 
at the beginning of the second school term, and in 
the first week of May. Unfortunately, at this third 
weighing 8 of the children could not be secured, 
so our results are for 27 instead of 35. At the first 
weighing all the children were within 3% of aver- 
age weight for their height, at the second weighing 
they varied from 9% under to 12% overweight, and 
at the final weighing the 27 children measured ranged 
from 8% underweight to 5% overweight. A marked 
variability is thus apparent, first in the general 
direction of gain, only two falling below the original 
minimum (—3%) for the entire group, later a very 
general trend in the direction of loss is apparent. 
It will be seen that the history of the Control Group 
exhibits the same general features as to variability 
shown by the Nutrition Groups and further confirms 
Dr. Porter's findings. 

EESULTS IN" WEIGHT INCREASE 

The comparative results achieved by the open-air 
and indoor groups are shown by Chart A, where the 
shaded column represents the fifth grade classes and 
the plain column the open-air classes. The base line 
indicates the periods for which results were cal- 
culated: A the first seven weeks, B the first twelve 
weeks, C after nineteen weeks, and D the final re- 



84 



HEALTH EDUCATION 



~3SO 
























.340 








930 








300 
480 
160 
140 


i 

'////// 




I 






§ 




130 
100 - 


I 




i 






j 




i////. 




i 




I 




§ 






p 






§ 

W/ 

i 

r /////j 




1 




i 




i 






n 






1 







13 
B 



19 
C 



30 



CHART A 

Comparative Gains, Fifth Grade and Open-air Classes 



DEVELOPMENT OF PROCEDURE 85 

suit, after twenty-seven weeks for the fifth grade 
and thirty-two weeks for the open-air classes. The 
height of the columns shows the average per cent 
of gain. It will be seen that the open-air classes 
in the first twelve weeks increased 274% of the nor- 
mal gain, whereas in nineteen weeks their increase 
was 125%, and in the entire period 111%. The first 
and final difference is not so great for the children 
of the fifth grade classes. In the first seven weeks 
between the original weighing and the first meeting 
of the class, the average gain in relation to normal 
was 208%. In the first twelve weeks it had decreased 
to 156% and was approximately the same at nine- 
teen weeks, but for the entire period it was only 
106%. 

The percentage of gain for the fifth grade class 
from week to week is shown in Chart B, the base 
line indicating weeks, and the figures at the left 
percentage of gain. The chief interest of this record 
is the fluctuation shown in parade week and again 
in promotion week. The loss incidental to the ex- 
citement and strain of examinations is approxi- 
mately 0.6%. The gain for the entire period of 
twenty-seven weeks is approximately 9%. 

Our attempts to find correlation between the per- 
centage of gain and such features of our procedure 
as caloric intake, -the number of rest periods ob- 
served, the number of lunches taken, were unsuccess- 
ful. With data gathered from a larger number of 
individuals it might have been possible to establish 
clear cut correlations but even so the evidence as to 
the value of any one of these taken by itself would 
hardly be convincing — such testimony would indi- 



86 



HEALTH EDUCATION 



TO 



6.0 



50 



40 



3.0 




XMAS 




TKO MOTION 



10 



20 



ts 



CHART B 

Percentages op Gain from Week to Week — Fifth Grade Class 

Note. — The fluctuation shown in the eighteenth week coincides with the date of ths 
parade by which the return of the city troops was celebrated. 



DEVELOPMENT OF PROCEDURE 87 

cate rather their value as contributing factors to the 
results obtained by the general regime. 

PHYSICAL DEFECTS 

Naso-pharyngeal Obstructions. — Thirty children, 
or 35% of the 87 enrolled, were recommended for re- 
moval of naso-pharyngeal obstructions, and of these 
23, or 76.6% of the number recommended, had opera- 
tions arranged for them in the course of the year, 
although the conditions incident to the influenza 
epidemic delayed the treatment in all but two cases 
until early Spring. Any resulting benefits therefore 
cannot have played an appreciable part in the class 
record of gains for the year. 

Of the 30 children recommended for operation, 13 
were from the open-air group and represented 27% 
of their total enrollment. This relatively low per- 
centage of naso-pharyngeal defects among the group 
of high percentile, chronic underweights was partly 
accounted for by the enrollment among them of chil- 
dren operated on the year before. The indoor groups 
also presented a better condition in respect to these 
defects than had been the case the previous year, 
only 17 children, or 44% of their enrollment being 
recommended for operation. 

Only 10 of the 23 cases operated secured treat- 
ment at a date early enough to permit a five weeks' 
period of observation after the necessary interval 
for weight recovery. Chart C shows the curve of 
gain for these 10 cases for five weeks previous to 
the operation, as well as for the five weeks following 
their recovery of weight. The intervening period, 
4.6 weeks, during which they were recovering from 



88 



HEALTH EDUCATION 



♦a. 



♦l 



-1 




S Weak* 
before 
Tonsil 
Oeera.ti.oa 



Operation 



S Week© 
m after 
Tonsil 
Operation 



CHART C 

Progress op 10 Children before and after Operation for 
Naso-pharyngeal Obstructions 



DEVELOPMENT OF PROCEDURE 



89 



the effects of the operation, is indicated by the dotted 
line. The percentage of gain is —.4% for the period 
before and 2.1% for the period after the defects 
were removed. 



MENTAL ABILITY 

The results of the comparative study of mental 
ability in underweight and normal children under- 
taken this year * were briefly as follows : In tests 
of motor control there was no marked difference 
shown between the Nutrition and the Control Group 
either in the separate series of tests as given at the 
beginning and at the end of the Nutrition Class 
period, or in improvement as shown by the differ- 
ences between the first and second results. When the 
combined scores for the two series are considered we 
get a slight difference in favor of the Control Group 
in the two tests measuring physical endurance — 
Rapidity of Movement (Tapping) and Strength of 
Grip (Dynamometer). In the Steadiness Test the 
Nutrition Group has a little advantage. 





Tapping 


Dynamometer 


Steadiness 




R. H. 


L. H. 


R. H. 


L. H. 


R. H. 


L. H. 


Nutrition 


298.5 
306.7 


269.4 
265.6 


32.0 
32.6 


29.6 
30.4 


4.8 
4.45 


3.55 


Control 


3.4 







In the following tests of mental processes the 
averages of the combined scores for both trials show 

* For a more complete report of this study see Malnutrition and 
Health Education, by David Mitchell and Harriet A. Forbes, Peda- 
gogical Seminary, March, 1920. 



90 



HEALTH EDUCATION 



superiority of the Nutrition Group in five of the 
seven tests. 





Nutrition 


Control 


Trabue Completion 


10.05 
6.4 
2.6 
3.5 
6.95 
6.9 
151. 


8.85 


Memory Span 


6.05 


Association Reaction Time 


3.1 


Directions 

Cancellation 


3.3 

5.95 


Knox Cubes 


7.3 


Dearborn Reconstruction 


148 5 







The Trabue Completion Scales which give a high 
correlation with standardized intelligence scales 
show similar distributions of scores. Superiority of 
the undernourished children is indicated. These 
average scores differ so little and the sampling is 
so small, one is not justified in asserting that sig- 
nificant differences are found between the two 
groups. It can be claimed that these undernour- 
ished children are equal in mental ability if not 
superior to the well-nourished children. 



INTERPRETATIONS 

Evaluation of procedures in this second experi- 
ment is more difficult than in the case of the preced- 
ing one, where groups were established on a fairly 
equal basis and with definite variables as points of 
comparison. It will be apparent, however, that the 
advantage in gain shown by the open-air classes is 
of significance in view of their personnel. The 
variety of retarding factors they exhibited must be 
borne in mind when we contrast the year's record 



DEVELOPMENT OF PROCEDURE 91 

made by them with that of the fifth grade. When 
allowance is made for the physical disparity between 
the two groups, and especially when we recall that 
of 48 open-air boys, 12, or 25% of the number, failed 
to respond at all owing to unknown factors pre- 
sumably of disease or organic deficiency, the facts 
of their relative response become emphatic. It 
would appear that the special factors determining 
this response must have particular significance for 
the efficient health program, if on analysis they can 
be isolated. 

It will be recalled that special emphasis was laid 
on fresh air in the fifth grade class-room and that 
their windows were kept open except in extreme 
weather. Thus it is evident that the results for the 
first twelve weeks shown at B (Chart A) were for 
gains made in a season during all, or nearly all of 
which the windows were kept open. In the interval 
between B and C, however, we may assume that the 
fifth grade was conducted as a closed-window class, 
with frequent changes of air by direct ventilation 
and temperature lower than that of the average 
class-room. During the greater part of the interval 
between C and D this arrangement must have ob- 
tained as the final determinations were made for the 
fifth grade early in May. Comparison of results at 
B, G and D, therefore, gives no evidence that open 
windows were a determining factor, as the superior 
gains of the open-air groups at B were made when 
the fifth grade was conducted as an open-window 
room, the superior gains of the fifth grade at C and 
its inferior gains at D seem to argue the dependence 



92 HEALTH EDUCATION 

of the results obtained on factors other than open 
air. 

The food experiences arranged for the open-air 
groups were much better calculated to influence gains 
than those given to the fifth grade. The hot mid- 
morning luncheons of cereal and milk or cocoa were 
admirably calculated to supplement the home diet- 
ary and educate a taste for the milk and cereals so 
lacking in the Jewish bill of fare. The meagre cold 
lunches brought from home by the fifth grade boys 
added little to the actual caloric intake and nothing 
to the broadening of dietary habits. But there is 
probably an added reason for the greater effective- 
ness of the lunches served to the open-air groups in 
the undoubted stimulation to metabolism and conse- 
quent better assimilation resulting from out-of-door 
atmosphere. We may go further in making our com- 
parison here and infer that the inadequate lunches 
brought by the fifth grade boys were less adequate 
during the period of open windows, when metabo- 
lism and assimilation were thus stimulated, and more 
adequate in the period preceding the determinations 
made at C, after a season of closed windows.* 

Comparison of the rest periods for both groups 
of children is obviously greatly in favor of the open- 
air classes. Indeed it is hardly an exaggeration to 
say that the rest periods in the fifth grade provided 
a dramatic rather than a real experience of rest, 
although a certain conception of relaxation and how 
to secure it was doubtless gained by the children. 

* See Hill, Leonard, special report, English Medical Eesearch Com- 
mittee, The Science of Ventilation and Open Air Treatment, Part I, 
1919. A series of observations on heat production of man in- and 
out-of-doors is discussed. 



DEVELOPMENT OF PROCEDURE 93 

Again, we cannot isolate the factor of rest from that 
of temperature, but must consider the combined 
effects of both in estimating the open-air environ- 
ment. That the physiological effects of rest and 
sleep in cold air with warm body coverings are of 
particular tonic value, is a fact well recognized in 
therapeutics although as yet not fully explained by 
science. That blood pressure is thereby increased, 
heart action strengthened, and nerves steadied, has 
been demonstrated in some cases of acute illness, 
notably pneumonia.* 

How far data on the blood pressure and heart 
action of well children under similar conditions may 
serve to reinforce the open-air program has yet to 
be ascertained. It seems apparent, however, that 
the significance of the open-air class does not lie in 
any one of its special provisions but rather in the 
physiological effect resulting from the interaction 
of all three. 

The factor of sunshine like that of "fresh" air 
evidently played no determining part in securing 
results, as the open-air class-rooms both had a south- 
ern exposure and were flooded with sunshine, while 
the fifth grade was in a north room until mid-year 
or during the two periods A to B and B to C, when 
their gains were successively less and greater than 
those of the open-air boys. 

Cooperation on the part of the children and of 
the homes was fairly comparable in both groups, 
although interest was probably established some- 
what earlier in the open-air classes, because of their 

* See Discussion of Papers on Fresh Air Schools by Dr. John W. 
Brannan — Transactions Fourth Int. Congress on School Hygiene, 
1913, Vol. II, p. 171. 



94 HEALTH EDUCATION 

special significance in the minds of both parents and 
children, and because of the number of children in 
them carried over from the experiment of the year 
before. The longer period of educational influence 
to which these had been subjected may well have re- 
sulted in better cooperation at the outset, and 
greater gains during the period of maximal weight 
increase may also have resulted from a previous im- 
provement in their home regime. The removal of 
tonsil and adenoid defects during the preceding year 
probably proved a contributing factor too, but we 
must assume that these possible advantages could 
hardly offset the failure on the part of 25% of their 
total enrollment to gain at all. Bather it seems rea- 
sonable to accept the difference between the gain of 
274% and 156% shown at B, as the probable increase 
resulting from the combined environmental factors 
of lunches, rest, fresh air and lighter school pro- 
gram at the season specially favorable to increase, 
over and above the gains to be expected from the 
seasonal period itself and the program of instruc- 
tion. 

The results shown at C suggest that the sea- 
sonal period of minimal growth may retard gains 
for the high percentile underweight rather more 
than for the low percentile and normal child, and 
that the advantageous factors of environment for 
the open-air classes were insufficient to compensate 
for the better resistance to winter conditions offered 
by the fifth grade, who were now probably beginning 
to show the results of educational influences and im- 
proved home regime, in addition to their better 
physical endowment. 



DEVELOPMENT OF PROCEDURE 95 

The determinations at D demand a special word 
of explanation. As all but two of the children oper- 
ated for tonsil and adenoid obstructions during the 
school year were treated in the period between C 
and B, results for weight increase in both groups 
are correspondingly lowered. In addition the gen- 
eral discouragement felt by children and parents as 
the year drew to a close and it became obvious that 
the promised results of the nutrition program were 
not being realized, resulted at last in lessened 
efforts and frequent lapses in regime. Thus the 
lessened results at D are really not representative 
and a final estimate of the year's work should not be 
based on them.* 

So far as the results shown by Chart A lend them- 
selves to analysis, we may conclude their testimony 
is to the importance of environmental factors for 
securing early results, and to the better ability of 
the low percentile and normal child to gain, even 
under less favorable circumstances of environment, 
during the period of minimal weight increase. 

Summary 

In June, 1919, after a full school year of intensive 
work our results in terms of weight increase ap- 
peared so slight as to be almost negligible. Appre- 
ciable improvement in our procedure had not 
brought corresponding gains to the children in our 
classes. In spite of more adequate physical care, 
increased control of the environment and better 
teaching technique, we seemed as far from our goal 
as we had been in the previous June. The facts of 

* See later showing of fifth grade boys, pp. 146 and 149. 



96 HEALTH EDUCATION 

Dr. Porter's investigation, it will be remembered, 
were not available to our workers until nearly twelve 
months later, and we were therefore without the key 
by which our apparent failure could be properly in- 
terpreted. The initial gains of the fall were for- 
gotten, in view of the inexplicable failure to gain 
through the second term of school, and as the year 
progressed and the discouragement of the season 
of minimal increase was felt by all, the educational 
fallacy of holding out to the children promises of 
results that were not to be realized, however well 
informed or willing their cooperation, was keenly 
appreciated by the members of our staff. 

While the conviction remained with those who had 
observed the fifth grade class, that such a subject 
matter program as had been developed for them was 
a valuable addition to the procedure, the statistical 
data for the year brought into relief the better show- 
ing of the open-air classes, and emphasized the im- 
portance of more adequate provision in the school 
environment for the actual practice of health-mak- 
ing activities by contrast with class discussion of 
them. As a natural corollary the importance of 
parental cooperation to provide increased opportu- 
nities for a health-making regime at home received 
corresponding emphasis. 

But the development of a subsequent program 
planned to secure further enlistment of home co- 
operation, and to permit greater emphasis on ac- 
tivities and environmental conditions in the school, 
hardly promised a solution of our major problems, 
even though the general efficiency of our procedure 
should be increased thereby. Our experience with 



DEVELOPMENT OF PROCEDURE 97 

the "graduates" of the early fall who later fell back 
into the ranks of underweight, and the fluctuations 
shown by the control group had raised serious ques- 
tions as to the standards we were using. The failure 
to secure response from, or even to diagnose the 
twelve cases transferred from the groups of the 
previous year to the open-air classes, indicated the 
insufficiency of our knowledge in regard to certain 
types of malnutrition. The need for a program of 
study involving more detailed observations of height 
and weight increment, and more careful physical ex- 
amination and diagnosis had become apparent, if we 
were to make real progress in solving the problems 
raised by our experience. Moreover, the negative 
results from our study of mental ability called for 
further investigation in this field, where we had ob- 
tained findings so much at variance with precon- 
ceived opinion. 



CHAPTER V 

DEVELOPMENT OF PROCEDURE— PRIMARY 
GRADES— SEPTEMBER, 1919— JUNE, 1920 

Basis of Reorganization 

In planning our work for the next school year it 
was decided to experiment with first grade children 
and to concentrate our efforts on developing a pro- 
cedure suited to their needs. It will be recalled that 
our initial program in 1918 included a first grade 
class and that they had shown surprising gains in 
comparison with the other classes, in spite of the 
fact that little attempt had been made to adapt our 
procedure to the special demands of their age period. 
In the belief of our workers the great solicitude felt 
by the parents for children in their first school year, 
and the type of home cooperation afforded in conse- 
quence, offered an explanation of our relative suc- 
cess with the first grade class; and it was believed 
that by development of a program further enlisting 
home cooperation for such a group, proportionally 
better results could be secured. At the same time, 
the first grade was felt to be the logical beginning 
for any program of instruction depending in the 
main on activities rather than subject matter. If 
school tradition still confuses the teacher who is 
trying to think in terms of activity rather than in- 
formation, the same is equally true of the nutrition 

98 



DEVELOPMENT OF PROCEDURE 99 

worker. But in classes where the possibility of in- 
formational content is reduced to its lowest terms 
by the limitations of the age period, it would seem 
possible to carry out such a change in class proce- 
dure to the best advantage. The immaturity of the 
six-year-old makes equally impossible the reduction 
of the educational program to informational mate- 
rial, and the shifting of responsibility for gains from 
the adults in control of the environment to the child 
himself. 

In addition to our program for first grade children, 
the boys of the previous year's fifth grade class were 
weighed and measured monthly, with a view to 
studying their record and determining, if possible, 
any long term results that might have been afforded 
by the nutrition class procedure. Careful measure- 
ments of control groups for both classes, the first 
grade and the previous year's fifth grade were 
planned, more thorough physical examinations were 
arranged, and a more extensive program of mental 
measurements was included. 

GROUP SELECTION 

Forty first grade children ranging from 8 to 20% 
underweight were enrolled in the nutrition class 
organized in September, 1919. The group was seg- 
regated and an experienced class-room teacher who 
was interested to cooperate with the nutrition staff 
was assigned them for the school year. Owing to 
the early transfer of 2 boys the class was reduced 
to 38 members. Of this number 8 were replaced 
later in the school term because of transfer to other 
schools or failure of promotion at mid-year. 



100 HEALTH EDUCATION 

In February, 14 children from 7 to 22% under- 
weight for height, were found among the mid-year 
entrants to the first grade.* These formed a second 
nutrition group. Associated with them were 5 boys 
not promoted with the September group. 

School Procedure. 

INDIVIDUAL INSTRUCTION 

Weights were taken weekly in the eye clinic room 
and the results written on a report slip for each 
child to take home. These slips created much inter- 
est at home and among the children. Every other 
week individual instruction was given in connection 
with the weight taking. The child's chart was used 
and his progress marked by a red crayon dot placed 
on it in his presence, the black line being filled in by 
the nutrition worker afterwards. Neither the "nor- 
mal weight line" nor the line of "expected gain" 
appeared on the charts,! and the boys were not con- 
scious of being underweight, they were simply en- 
couraged to form health achieving habits, to try 
to make gains and if possible to beat their own pre- 
vious records. In the beginning the charts were 
meaningless to them, as they could not read their 
own names nor follow the figures; but they soon 
grasped the significance of the "up and down" 
weight line. 

CLASS INSTRUCTION 

On alternate weeks class instruction was given by 
the nutrition worker for a period of fifteen minutes 

*See "Growth in Weight and Height," p. 119. 
t See Appendix C. 



DEVELOPMENT OF PROCEDURE 101 

and included a story. The chart showing the best 
progress for the fortnight was displayed on the wall 
and attention called to it as a recognition of achieve- 
ment. Except for these best records the children 
saw only their own charts, and discussed their indi- 
vidual progress only with the nutrition worker, or 
at home. 

A special subject for class discussion was selected 
for each month;, and the short stories told at the end 
of the session were chosen to emphasize the subject 
under consideration. Each contained an obvious 
and simply expressed lesson on health habits, and a 
feature was made of repetitive and rhythmical para- 
graphs in which the class could join and thereby 
secure the active sense of participation so important 
for holding interest at this age period. "What the 
Milk Told Me," "The Pig Brother," "How Bobby's 
Food Turned into More Bobby," "The Rain-drops," 
"Little Potato," were the stories successfully used 
for these children.* Their recital was followed by 
informal discussion and by the spontaneous dram- 
atizations characteristic of modern story telling for 
the primary grades. The particular content covered 
by the series involves the importance of cleanliness, 
of water drinking, of milk and vegetables in the diet, 
and a conception of the processes of digestion, re- 
duced to very simple terms. The class dramatiza- 
tion of "The Story the Milk Told Me" was given 
by 12 of the boys at the Grand Central Palace during 
the week of the New York Milk and Child Health 
Campaign. The breakfast food models were shown 

*"What the Milk Told to Me," by Gertrude Noyes, from the 
collection In the Child 's World, by Poulsson ; ' ' The Pig Brother, ' ' by 
Laura E. Bichards; the other three stories are unpublished. 



102 HEALTH EDUCATION 

in connection with, class discussion, and were supple- 
mented by specimens of fresh green vegetables 
brought by the nutrition worker. 

ENVIRONMENT 

Lunches. — The attempt to have mid-morning 
lunches provided by the homes was definitely aban- 
doned and an 8-ounce glass of good milk substituted 
for the uncertainties of home catering. This was 
served at the Nathan Straus Milk Station in Tomp- 
kins Square at 10:15 every day, when the children 
went over to the square for their playground period. 
Later, when severe weather made this impracticable, 
the milk was delivered at the school by special ar- 
rangement and served by the class teacher. Each 
child brought his own cup from home, and these were 
kept in one of the class-room cupboards, and washed 
after school by one of the janitor's assistants. This 
cooperation on the part of the Nathan Straus milk 
depot made it possible to serve really delicious milk 
at a nominal cost. The expense was partly met by 
the children who paid a cent a day for it. For 
many this was their first experience with milk as a 
cool and palatable beverage. Several of the mothers 
had fears as to its safety and healthfulness, and were 
reassured only with difficulty; but it soon became 
popular with the children. Although adding only 
about 150 calories to the daily intake, it proved a 
most satisfactory solution of the mid-morning lunch 
problem for this group of children. Mid-afternoon 
nourishment was provided at home by the mothers. 

Rest. — As in the fifth grade class of the previous 
year, rest periods were taken in the seats for a 



DEVELOPMENT OF PROCEDURE 103 

few minutes each day under the class teacher's 
supervision. 

The double session schedule necessitated a noon 
period of an hour and a half for children of the 
X-school, to which the nutrition class belonged, and 
as all the children lived in the near neighborhood, 
rest periods of from twenty to thirty minutes at 
home were advised. Owing, however, to congested 
home conditions mothers found this too difficult a 
task to accomplish with any degree of regularity. 

FEBRUARY ENTRANTS 

The group of 19 children recruited from those 
found underweight among the entrants to the first 
grade at the beginning of the second term, was not 
segregated as the September group had been be- 
cause, even after the addition of 5 boys from the 
September group who failed of promotion, their 
total number (19) was too small to organize an entire 
class for them. They were divided between the two 
first grade classes enrolled in February, and the 
nutrition worker was assigned a weekly period in 
each class. On alternate weeks when the group in- 
struction was given and stories told, all the pupils 
in the room shared in the experience. Thus, for 
the first time the children of the control group, 
and members of the class who were not subjects of 
special care or study, were included in this part of 
the nutrition program. 

Mid-morning milk was provided for the children 
of the nutrition group only and they were excused 
from their own class-rooms for a fifteen-minute 
period each morning to get it. It was served in 



104 HEALTH EDUCATION 

one of the open-air class-rooms at the same time 
that the open-air boys received their mid-session 
luncheon. 

Home Cooperation 

The attempt to secure the attendance of mothers 
at the weekly class sessions was definitely abandoned 
at the beginning of the year, as we felt that without 
far more energy and time than we had at our dis- 
posal, we could not present a claim sufficiently im- 
portant to outweigh the pressure of work for a large 
family, the demands of the shop or push-cart, or the 
inertia incident to a foul environment. A monthly 
mothers' meeting was tried as a substitute, in the 
belief that the greater convenience and attractive- 
ness of a meeting, arranged at less frequent inter- 
vals, and entirely with a view to adult interests, 
would make a stronger appeal, but the relative suc- 
cess that followed this change was due to other fac- 
tors as well. It seems reasonable to believe that 
results of our attempts in the two previous years 
to enlist interest and confidence were beginning to be 
felt in the community ; in addition, the general health 
propaganda stimulated by the war may have perme- 
ated the neighborhood sufficiently to have had an 
effect. Then too, the mothers of first grade children 
form, in many respects, an ideal group to be ap- 
proached. Many of them have small families and 
are launching a child for the first time on his school 
career. Some, through the kindergarten, have 
already made social contact with the school a fa- 
miliar experience. Moreover, the type of mother 
represented in this group has not yet resigned her 



DEVELOPMENT OF PROCEDURE 105 

child to outside influences to any such degree as she 
tends to do later on. Many still hold rather freshly 
in mind the precepts received through the baby 
clinic and the prenatal work of welfare workers, and 
it is thus relatively easier to get attention on mat- 
ters of growth and development at this period than 
later on. 

The factors working for increased cooperation 
were apparent early in the fall when parents were 
asked to be present for the physical examinations. 
Twenty-one mothers and two fathers responded, 
60.5% of the thirty-eight requests sent out at that 
time. Later in the term when stool and urine ex- 
aminations were undertaken, 34 specimens or 58.6% 
of the number requested were brought to the school 
at the appointed time. 

mothers' meetings 

Postal cards sent to all the mothers of the first 
grade nutrition class announced the first mothers' 
meeting, and stated that the school desired to see 
present every mother who was interested to cooper- 
ate with us in a special health program. The re- 
sponse was felt to be encouraging, as nearly half the 
number were present at the first meeting. It was 
held in the eye clinic room. The large individual 
charts were hung against the black-boards, and these 
were explained to each mother separately before 
the meeting. This gave a pleasant informality at 
the start. As it seemed important for the mothers 
to realize that our work held a real place on the 
school program, Dr. Marks, the Principal, was pres- 
ent at this first meeting and at our request outlined 



106 HEALTH EDUCATION 

for them the need for the work, the opportunity 
that the school was offering, and their responsibility 
for any success that the new class might achieve. 
This he did skilfully and aroused a sense of pride 
in the venture that carried throughout the entire 
year. The nutrition worker in charge then pre- 
sented a few of the specific objectives for which we 
expected to work, and for the attainment of which 
the help of the home was essential. As a result there 
was a promise to stand by us, and we felt at the 
end of the year that the interest stimulated at this 
initial meeting had been really well-sustained 
throughout the period. 

The meetings were held each month from October 
to June with an average attendance of a third of 
the group. The women responded to notifications 
with very little special pleading on our part. Dr. 
Marks or his assistant usually attended, and the 
class-room teacher was always present and met the 
mothers informally after each session. 

Attendance cards were distributed and consider- 
able pride was shown in presenting them to be 
punched. At the last meeting several prizes were 
given to those having the best showing on the cards. 

In formulating a program for these meetings we 
aimed to create a background of knowledge regard- 
ing bodily processes explaining the reasons for our 
concern with the underweight child. We took up 
for discussion simple matters of personal hygiene, 
more or less familiar in the abstract, but which we 
knew often failed to function in action, because of 
entire lack of understanding of the body mechanism 
and the laws governing growth. The exhibit of food 



DEVELOPMENT OF PROCEDURE 107 

models was used, and the stories told the children 
were occasionally retold to the mothers, with a view 
to informing them in regard to the class-room in- 
struction. We were careful to attack only one im- 
portant matter at a time, and much important 
ground was thus left uncovered at the end of the 
year. The following topics were discussed with the 
mothers ' group : 

Milk: an essential food for the growing child. 

Sleep: why the young child needs more sleep than the adult; 
the conditions most advantageous for sleep, and their value to all 
the family. 

Food: what kinds are best for children; how best prepared and 
served; purpose of the different kinds of foods. 

Health Habits: water drinking, its use and abuse; need of 
establishing slow eating and thorough chewing; elimination of worry 
and emotional disturbance at table; need of daily rest period, with 
emphasis on its desirability before eating; need of securing regu- 
larity of stool, and conditions necessary to obtain this, bad results 
of depending on the use of cathartics or enemata; results of stool 
and urine examinations explained. 

Dental Care: the need for — emphasis on the treatment of the 
first teeth. 

As the year progressed the members of our staff 
became increasingly aware of appreciable results 
due in part at least to these discussions at the 
mothers' meetings, among them the following: (1) 
Increased interest in milk-drinking. The frequent 
remark which we had at the beginning, "My child 
won't drink milk," was very soon replaced by the 
announcement that "Maxie must have his penny now 
every day for milk," or "He loves now to drink 
milk; I must buy." (2) More use of cereal foods 
and green vegetables. (3) Attempts in a few cases 
to supervise a daily rest-period and in general an 



108 HEALTH EDUCATION 

increase in the number of children put earlier to 
bed. (4) The excellent returns in securing the stool 
and urine specimens. 

Throughout the year home visiting was continued 
and no attempt was made to curtail this part of the 
nutrition worker's program. The average number 
of visits paid each family was five, but when children 
were recommended for the correction of defects, the 
number was often considerably increased. Data on 
family measurements of weight and height were 
gathered during the home visits. This was a matter 
of interest to all members of the family, and 24 
fathers, representing 41% of the families, were in- 
terviewed on the subject in their homes by the 
nutrition worker. The considerate attention paid 
the mother by the Bureau physician at the time of 
the physical examination did much to establish con- 
fidence at the outset, and the weekly slips sent to the 
homes reporting the results of weight-taking, con- 
tributed materially to sustaining interest. 

COBEECTION OF DEFECTS 

Twenty-one of the 58 children given physical ex- 
aminations, or 43.5% of the total enrolled, were 
recommended for tonsil or adenoid operations. Ten 
cases were recommended for operation in the fall. 
At the same time eleven more were recommended 
for observation and of these, all were recommended 
for operation in March. These recommendations 
came too late, however, to secure necessary arrange- 
ments before the end of school and therefore the 
total number operated, 8 cases, was relatively small, 



DEVELOPMENT OF PROCEDURE 109 

only 38% per cent of the number recommended. The 
Post-Graduate Hospital received them. 

The record for dental work was far better, as 45 
of the 48 children enrolled in the September group 
were examined and 38 or 65.5% were treated, 10 
by the family dentist. The remainder were taken 
to the Stuyvesant Clinic or were treated by Dr. L. 
A. Leichter, a dentist, whose office adjoined the 
school and who generously offered to give his ser- 
vices, but in accordance with a suggestion from our 
staff decided to ask a nominal fee. A developing 
disposition on the part of the parents to pay the 
fees was one of the most encouraging features of 
the year's experience. Fourteen mothers paid the 
fees for dental treatment in full; others paid in 
part. The total work done amounted to 76 fillings 
and 74 extractions. 

It was found impossible to carry out recommenda- 
tions for correction of defects found among the little 
group enrolled in February. As we were unable 
to begin the nutrition procedure for them until 
March, the period available was too brief to secure 
the necessary permissions from parents, and obtain 
appointments at the various crowded clinics. 

Physical Examinations 

Of the 58* physical examinations, 43 were done 
by the Bureau physician and 15 by Dr. I. H. Gold- 
berger, a physician of the Board of Education. 

* Of the total number (62) enrolled during the year, 4 were trans- 
ferred before physical examinations had been made; thus the tabu- 
lations in Dr. Lincoln's report are for a total of 58. 



110 HEALTH EDUCATION 

Partial reexaminations were done by the Bureau 
physician on 11 cases. 

The mother was usually present at the examina- 
tion and was encouraged to ask questions regarding 
the child, and a short interview was usually given 
at the close of the physical examination, giving re- 
sults of the examination and recommendations. 
Occasionally, in order to stimulate the confidence of 
the mother, advice about her own condition was 
given when requested. 

As complete a general physical examination as 
possible was given to each child, consuming on the 
average half an hour, including otoscopic examina- 
tion and rough hearing tests. No eye examination 
beyond the usual routine was done, as all these chil- 
dren were examined in the eye clinic of the Board 
of Health in whose room the physical examinations 
took place. 

No attempt was made to diagnose tuberculosis 
except on physical signs. The only case suspicious 
of pulmonary tuberculosis was referred to the chil- 
dren's tuberculosis clinic at Bellevue Hospital, and 
was taken there by one of the nutrition workers for 
x-ray and the von Pirquet test. No other tuberculin 
tests were made. 

Besides the routine examinations of the heart, 
exercise tolerance tests were occasionally done on 
suspicious cardiacs. One case diagnosed as cardiac, 
and one suspected case were cardiographed at Belle- 
vue Hospital by Dr. Kelley. 

Stool examination was done on 47 cases and urine 
examination on 49 out of 58 children. These were 
added in the first place as further means of diag- 



DEVELOPMENT OF PROCEDURE 111 

nosis, and proved of particular value for convincing 
the mother in cases where corrective dietetic meas- 
ures were indicated. An undernourished child, 
whose mother is concerned about his condition, is 
apt to receive extra rations of food considered fat- 
tening, especially carbohydrates, but often in the 
cases of the Jewish children studied, an attempt is 
made to add to the diet by giving cream with food, 
or even as a beverage. Obviously where there is 
faulty digestion of any one food component and 
particularly in the case of fats, no good and pos- 
sibly harm can be done by overfeeding this element 
of the food. 

In addition to the large number of cases of con- 
stipation, 22 out of 47, 5 cases of fermentation were 
found, large numbers of undigested starch cells in 
11 cases, of undigested muscle fibres in 8 cases, and 
a large amount of neutral fat in 3 cases. 

Since no second examinations were made, it is 
recognized that these results are not unimpeachable ; 
but at least they are very suggestive, and corrective 
dietetic measures were instituted in the cases of fer- 
mentation and fatty indigestion and constipation, 
because of the large proportion of cases confirmed 
by stool examination. 

It was decidedly a surprise to find all the stools 
negative for ova and parasites on routine examina- 
tions. Oscar M. Schloss * in consecutive examina- 
tions of the stools of 280 children found parasites 
or ova in 28.5%, 78% of the positive cases being in 
children over five years of age. For this reason a 

* Schloss, Oscar M., American Journal of Medical Science, May, 
1916. 



112 HEALTH EDUCATION 

second examination was made in 10 cases taken with- 
out selection from the nutrition group. Stools from 
these cases were examined by the Loop Flotation 
Brine method of Kofoid and Barber,* this being the 
method used in the army in search for parasites and 
ova.f All these stools were again negative. 

Urine examinations were negative in 48 out of 
49 cases, albumen being present on one occasion in 
one specimen. They were therefore not nearly so 
suggestive nor helpful as stool examinations. 

Owing partly to the difficulties encountered in the 
examining room, due to its size, proximity to street 
noises, and numbers of mothers and children wait- 
ing for examination, a good many discrepancies and 
omissions occur on the charts. They cannot there- 
fore be used to obtain exact statistics regarding 
presence or absence of abnormalities in this group 
of undernourished children. In some instances, how- 
ever, the records are fairly complete, as on teeth, 
where note of some kind has been made on each child 
examined, even if the number of decayed teeth has 
not been mentioned. 

No. of No. of 

Geneeal Condition :Cases % Muscle Tone: Cases % 

Good 13 22.4 Firm 13 22.4 

Fair 14 24.1 Fair 19 32.7 

Poor 8 13.8 Flabby 21 36.2 

Not noted 23 39.7 Very flabby 1 1.7 

Not noted 4 7.0 

Total 58 100.0 Total 58 100.0 

* Kofoid and Barber, Journal of the American Medical Society, 
Vol. LXXI, p. 1557. 

t Kantor, Journal of the American Medical Society, July, 1919. 



DEVELOPMENT OF PROCEDURE 



113 



No. of 
Breathing: Cases 

Obstructed 9 

Partially obstructed. . . 21 

Free 22 

Not noted 6 

Total 58 100.0 





No. of 




% 


Tonsils: Cases 


% 


15.5 


Complete removal. ... 2 


3.4 


36.2 


Apparently normal. ... 12 


20.7 


38.0 


Moderate enlargement 




10.3 


only 8 

Very large or with evi- 


13.8 




dences of disease ... 36 


62.1 



Total, 



58 100.0 



No. of 

Teeth: Cases % 

One or more decayed . . 52 89 . 7 

None decayed 6 10.3 

Total 58 100.0 

No. of 

Approximation Cases % 

Good 27 46.6 

Fair 8 13.8 

Poor 9 15.5 

Bad 1 1.7 

Not noted 13 22.4 

Total 58 100.0 

No. of 

Ears: Cases % 

Drums— Normal 22 38 . 

Thickened... 17 29.2 
Otherwise dis- 
eased 7 12 . 1 

Not seen 7 12.1 

Not noted... 5 8.6 

Total 58 100.0 



No. of 

Glands: Cases % 
No enlargement of 

glands 4 7.0 

Moderate enlargement 38 65.4 

Marked enlargement . . 16 27 . 6 

Total 58 100.0 

Note. — Marked enlargement in- 
cludes both general glandular en- 
largement and marked enlarge- 
ment of a single group of glands. 
Thyroid was palpable in one case 
only. 



No. of 

Eyes: Cases % 

Normal 30 51.7 

SI. conjunctivitis 14 24.1 

Conjunctivitis 3 5.2 

Marked conjunctivitis. 2 3.4 

Strabismus 2 3.4 

Stye 1 1.7 

Blepharitis 3 5.2 

Sluggish reaction to 

light 1 1.7 

Not noted 3 5.2 



114 



HEALTH EDUCATION 



No. of 

Heart: Cases % 

Normal 50 86.2 

Poor muscle sounds ... 2 3.4 

Organic murmurs 3 5.2 

. Enlargement 3 5.2 

Diag. of cardiac disease 2 3.4 

No. of 

D'Espine Sign: Cases % 

Negative 35 60.3 

Positive 23 39.7 

Total 58 100.0 



No. of 
Abdomen: Cases 

Normal 36 

Prominent 13 

Hernia or enl. ring. ... 10 
Umbilical hernia. 2 
Inguinal hernia. . 8 
Lax muscles 1 

No. of 
Extremities: Cases 

Normal 22 

Enlarged epiphyses ... 1 

Knock knees 23 

Bowing of tibiae 1 

Hyperactive reflexes . . 17 

Knee jerks 16 

Upper reflexes.. . 1 

Babinski 2 

Edema 1 



% 
62.1 
22.4 
17.3 



1.7 



% 
37.9 

1.7 
39.7 

1.7 
29.3 



3.4 
1.7 





No. of 




Lungs: 


Cases 


% 




.... 52 


89.7 




.... 4 


6.9 




2 
.... 58 


3.4 


Total 


100.0 



Note. — D'Espine Sign has been 
considered positive where in- 
creased whispered voice was 
heard at or below the third dor- 
sal vertebra. There were 5 
cases not heard below the third. 

No. of 

Genitals: Cases % 

Normal 45 77.6 

Undescended testicles . 10 17.3 

Phimosis 2 3.4 

Other condition 1 1.7 

Total 58 100.0 

No. of 

Skin: Cases % 

Normal 50 86.4 

Pediculosis 2 3.4 

Scabies 1 1.7 

Alopecia areata 1 1.7 

Not diagnosed 2 3.4 

Not noted 2 3.4 

Total 58 100.0 



DEVELOPMENT OF PROCEDURE 



115 



No. of 
Mucous Membrane :Cases % 

Good color 19 32.7 

Fair color 12 20.7 

Pale 20 34.5 

Not noted 7 12.1 



Total 58 100.0 



No. of 

Chest: Cases % 

Normal 26 44.8 

Harrison's groove: 

Slight or moderate.. 20 34.5 

Marked 4 6.9 

Depressed sternum. . . 11 19.0 

Rosary 3 5.2 

"Rachitic" 1 1.7 

Flat 2 3.4 

Narrow 1 1.7 



No. of 



No. of 



No. of 



Spine: Cases % Feet: Cases % Posture: Cases % 



Kyphosis.. 5 



8.6 Normal.. 33 56.9 Poor 11 19.0 



Scoliosis.. 3 5.2 Weak 

Lordosis... 3 5.2 — 

Normal... 47 81.0 Total. 58 100.0 



25 43.1 Good 5 8.6 

— Not noted 42 72.4 



Total. . 58 100.0 



Total... 58 100.0 



No. of 
Stool Examination: Cases % 

Not examined 11 19.0 

Normal 15 25.9 

Constipated 22 38.0 

Fermentation 5 8.6 

Many undigested starch and vegetable cells .11 19 . 

Many undigested meat cells. . . 8 13.8 

Much free fat and many fatty acid crystals .3 5.2 

Ova and parasites not found. 

No. of 



Urine: 



Small amount of 






mucus 6 






Albumen on one occa- 






sion 


1 


1.7 




9 


15.5 



No. of 

Cases % Electrocardiograms: Cases % 

1 

1 



Normal 48 82 . 8 Slight left preponderance . 1 

Right preponderance with 
poor muscle tone 1 



Total 58 100.0 



116 



HEALTH EDUCATION 



Recommendations 



No. of Cases 



Per Cent 



Dental care 

Removal of jaw polyp 

Tonsillectomy and adenoidectomy or ade- 

noidectomy alone 

Observation of nose and throat 

Eye examination 

Treatment scabies 

Cardiac precautions 

X-ray chest advised 

Circumcision 

Observe testicles 

Observe hernia 

Foot exercises 

Other corrective measures 

Attention to posture, including exercises. 

Dietetic advice 

Tonics given 

General hygiene 

Hygiene for eneuresis 

Observe for achondroplasia 



52 
1 

20 

20 

9 



89.7 
1.7 

34.5 
34.5 
15.5 

1.7 



2 


3.4 


1 


1.7 


1 


1.7 


4 


6.9 


1 


1.7 


20 


34.5 


1 


1.7 


4 


6.9 


3 


5.2 


2 


3.4 


1 


1.7 


1 


1.7 



1.7 



DEVELOPMENT OF PROCEDURE 



117 



September and February Nutrition Groups 
Per Cent Underweight of Children with Physical Defects 





First Weighing 


Last Weighing 




No. of 

Cases 


Av.% 
Under- 
weight 


P.E. 


Av.% 
Under- 
weight 


P.E. 


P.E.D. 


D 




P.E.D. 


Fermentation 

Poor general condi- 
tion 


5 

9 

22 

17 
10 
36 
22 
24 


14.40 

10.88 
11.77 

9.41 
10.40 
10.64 
10.09 
11.04 


1.232 

.4284 
.5415 

.4946 
.4061 
.3040 
.3394 
.3329 


10.20 

9.00 
8.95 

6.59 
5.70 
7.33 
5.82 
5.58. 


1.568 

.5510 
.5974 

.5676 
.7067 
.4743 
.5600 
.5198 


1.994 

.6979 

.8062 

.7528 
.8150 
.5633 
.6547 

.6172 


2.106. 
2.693 


Poor muscle tone . . 
Hyperactive re- 
flexes 


3.495 
3.750 


Decayed teeth .... 
Diseased tonsils . . . 

Constipation 

Harrison's groove. 


5.766 
5.876 
6.527 

8.843 


Sept. and Feb. nu- 
trition groups. . . 


58 


11.20 


.2880 


7.37 


.3769 


.4743 


8.077 



CHAPTER VI 

GROWTH IN WEIGHT AND HEIGHT 

First Grade Children 

SELECTION" 

The total number of entrants to the first grade 
classes of Public School 64, in September, 1919, were 
weighed and the height measured. One hundred 
and twenty-three of these boys were measured be- 
tween September 9th and September 24th. Two 
entered in October and one in November, making 
126, from whom the Nutrition Class was selected. 
Forty boys, ranging from 8% to 20% underweight 
for height, and with an average per cent underweight 
of 11.6, were segregated in this class. The early 
transfer of 2 boys reduced the group to 38. Of the 
boys weighed after September 18th, ten were found 
to be more than 8% underweight. By the first of 
December, four of these had entered the Nutrition 
Class to replace members who had been transferred 
to other schools, and in February, 1920, four more 
entered to replace boys who were not promoted with 
the group. The other two underweight boys are 
tabulated with the general group. 

A Control Group was formed of those nearest the 
normal standards for height-weight index at their 
ages. There were found 41 boys who ranged from 
4% above to 4% below normal weight for height, 

1X8 



GROWTH IN WEIGHT AND HEIGHT 119 

and 6 boys from 5% above to 8% below normal. The 
last case was included in the Control Group through 
error in first calculation. The average per cent 
underweight of this group was 0.83. 

Measurements were taken without shoes or coats. 
The Nutrition Group was weighed weekly from 
September to June, and the height was measured 
monthly. The Control Group was measured every 
two months and the others of the general group, not 
included in these two classes, were measured again 
in May, 1920. 

The chronological age of the Nutrition Group 
ranged from 5.25 to 7.39 years, with an average of 
6.3 years. The range for the Control Group was 
5.96 to 7.54 years, with an average of 6.3 years. The 
nationalities represented were as follows : 

Nutrition Groups 
September 1919 Group 

Russian 25 79|% Russian and Austrian 

Austrian 10 

Italian 2 

Galician 1 

Hungarian 4 

Rumanian 1 

German Jew 1 (Born N. Y. C.) 

February 1920 Group 

Russian 6 79% Russian and Austrian 

Austrian 5 

Hungarian 1 

German American 1 

Irish American 1 

In February, 58 boys entered the first grade 
classes. The} 7 were measured and a group of 14, 
ranging from 7% to 22% underweight, was formed 



120 HEALTH EDUCATION 

on March 2. Five boys of the September class, who 
failed of promotion, were placed with this group. 
Twenty-three entered school during March and 
April, and of these 7 ranged from 8% to 12% under- 
weight. Twenty-two boys of the February entrants 
formed a Control Group, ranging from 4% above to 
4% below normal standards. These mid-year en- 
trants were not segregated into groups, but divided 
between two class-rooms. 

DISTRIBUTION OF PERCENTAGES OVER AND UNDERWEIGHT 

Chart I represents the distribution of the percent- 
ages over and underweight for all the children who 
entered the first grades in September, 1919. Of 126 
children, measured at entrance in the fall, 8 were 
of normal height and weight ; of the remaining 118, 
25 or 21% were from 1-24% overweight and 93 or 
79% were from 1-24% underweight; 55 children or 
43.7% were from 8-24% underweight, 6 children or 
4.8% were from 16-24% underweight. Contrasted 
with these we have only 6 children or 4.8% who were 
from 8-24% overweight, 2 children or 1.6% who were 
from 16-24% overweight. 

There were 81 boys entering in February and 
March. Of these 10 were of normal weight for 
height, 29 were from 1-24% overweight, 16 were 
from 1-6% underweight, and 26 were from 7-22% 
underweight. 

If we take a seven per cent standard for select- 
ing the undernourished child, and if we consider 
this general group a typical one for the age, sex, 
stock and social group studied, we find nearly 50% 



GROWTH IN WEIGHT AND HEIGHT 121 







P 
O 
K 



5 <J 



o 

05 

B 

2; 

o 






H K a 



Ph 






s O 

o 



Oh t3 



"8 2 



122 HEALTH EDUCATION 

or half of them are undernourished when meas- 
ured in September; a little more than 25% or a 
fourth are undernourished when measured in Feb- 
ruary. The seasonal variations shown in all the 
groups studied would account for this difference in 
percentage between September and February. The 
large percentage found for the September group in- 
dicates need of more careful determination of the 
criteria of malnutrition or undernourishment. 

The children of the September Nutrition Group 
averaged 11.56% underweight at the first measuring, 
the range being from 8-20% underweight. The Con- 
trol Group averaged 0.83% underweight at that time, 
with a range from 8% under to 5% overweight. The 
wide variation between these two averages and the 
fact that the average percentage underweight of the 
Control Group so nearly approximates zero would 
seem to indicate that likenesses or differences be- 
tween these groups are significant ones and are not 
due to faulty selection from the standpoint of nu- 
tritional status. However the demarcation of 8% 
under for a Nutrition Group is not established, and 
the nutritional behavior of the children in both 
groups near this borderline should help to deter- 
mine standards of malnutrition. 

The accompanying tables, la and lb, show the per- 
centages underweight of the September Nutrition 
and Control Groups for October, December, Febru- 
ary, April, and June, according to the Burk-Boas 
norms of weight for height. These percentages are 
derived from a height and a weight taken on the same 
day, this day falling for a given month between the 



GROWTH IN WEIGHT AND HEIGHT 123 

8th day of that month and the 8th day of the preced- 
ing month. For example, the percentages underweight 
for October are based on a height and a weight meas- 
ured for any one individual on the same day, this 
day falling between September 8th and October 8th, 
etc. 

COMPARISON OP UNDERWEIGHT AND CONTROL GROUPS 

The total gain in weight is reckoned from the time 
the individual entered the Nutrition or the Control 
Class until approximately June 1st, when the last 
weighing was made, and includes those individuals 
who missed not more than four weekly weighings 
either at the beginning or the end of a period of 
eight months, during which the class was conducted. 
The deviations from normal gain are given for these 
same individuals and are obtained by subtracting 
the total gain in weight from the normal gain for 
eight months, as given by Burk and Boas. 

Similarly, Table II contains percentages for the 
minor groups, selected in the following February, 
for February, April and June, the measurements 
being made between the 20th of the given month and 
the 20th of the preceding month. The gains in 
weight are given for the children who missed not 
more than two weekly weighings either at the begin- 
ning or the end of the class period. The deviation 
from normal gain is obtained by subtracting the 
total gain for the class period from the normal gain 
for four months, as given by Burk and Boas. 

The Total Gain for the Nutrition Group (Table 
la) during the class period shows an average of 3.69 



124 



HEALTH EDUCATION 



TABLE I a 

Percentage Underweight 
September Nutrition Group 



No. 


October 


December 


February 


April 


June 


Total Gain 
(lbs.) 


Dev. from 

Normal 

Gain 

+ - 




+ - 


+ - 


+ - 


+ - 


+ - 


+ - 


1 


10 


5 


5 


8 


8 


2.7 


0.1 


2 


11 


7 


4 










3 


10 


3 


5 




5 


4.2 


1.4 


4 


11 


7 


7 


4 


8 


4.0 


1.1 


5 


9 














6 


8 





4 





2 


4.8 


1.9 


7 






7 


4 


7 






8 


11 


4 


2 


6 




4.0 


1.0 


9 


12 


10 


8 


6 


6 


3.9 


0.8 


10 


12 


7 


2 


7 


7 


3.6 


0.6 


11 


9 














12 


14 


7 


7 


7 


9 


2.7 


0.2 


13 


12 


7 


9 


7 


7 


4.1 


1.2 


14 


16 


9 


5 


7 


9 


3.8 


1.0 


15 


17 


9 


10 




12 


2.1 


0.7 


16 




8 


8 


8 


10 






17 


8 


4 


2 





4 


5.4 


2.5 


18 


20 


14 


10 


6 


9 


6.3 


3.3 


19 


12 


5 


5 


2 


7 


1.7 


1.2 


20 


8 


6 


2 








5.8 


3.0 


21 


12 


4 




6 


4 


4.6 


1.8 


22 


13 


11 


9 




10 


3.1 


0.2 


23 


12 


11 


9 


9 


12 


3.2 


0.2 


24 


10 


2 


5 


2 





3.0 


0.2 


25 


13 


9 


7 


10 


12 


2.0 


1.0 


26 


14 


7 


11 


9 


9 


3.1 


0.1 


27 


10 


7 


2 


2 


7 


1.4 


1.5 


28 


8 


6 


6 


2 





5.1 


2.0 


29 


12 


2 


2 











30 


8 


2 


6 


2 


6 


4.4 


1.6 


31 


9 


7 




4 


8 


3.4 


0.4 


32 


15 


5 


2 


2 


5 


2.6 


0.2 


33 


10 


10 


7 


9 


9 


1.9 


0.9 


34 


10 


12 


7 


2 








35 


16 


7 


9 


7 


11 


2.2 


0.9 


36 


9 







4 


2 


5.1 


2.1 


37 


14 


12 


11 




9 






38 


12 


7 


5 


4 


7 


2.7 


0.3 


39 


9 


2 


2 


2 





5.7 


2.9 


40 


12 


6 


6 


6 


4 


5.3 


2.3 


41 


14 














42 


12 


12 


10 


4 


9 






43 


10 




8 




10 






44 






8 


4 


6 






Av. 


-11.56 


-6.66 


-5.68 


-4.4 


-6.54 


3.69 


0.769 


a 


2.691 


3.330 


3.670 


3.217 


3.811 


1.305 


1.250 


P.E. 


.2725 


.3629 


.40 


.3667 


.423 


.1552 


.1487 



GROWTH IN WEIGHT AND HEIGHT 125 



TABLE I b 

Percentage Under or Over Weight 

September Control Group 



No. 


October 


December 


February 


April 


June 


Total Gain 
(lbs.) 


Dev. from 

Normal 

Gain 

+ - 




+ 


- 


+ - 


+ - 


+ - 


+ - 


+ - 


1 






4 




6 


6 


4.4 


1.6 


2 




4 








2 


4 


4.6 


1.6 


3 




6 


2 


2 





2 


4.0 


1.1 


4 




2 





2 


2 


2 


2.8 


0.0 


5 


5 






10 


7 


7 


1.2 


1.8 


6 




2 


2 


7 


5 


2 


3.5 


0.7 


7 


2 








4 


4 


3.3 


0.5 


8 




4 





2 





2 


3.6 


0.8 


9 




5 













4.0 


1.1 


10 










2 










11 




8 


4 


2 





2 


5.4 


2.4 


12 




2 


5 


2 


7 


2 


5.7 


2.8 


13 




4 





2 


2 





4.7 


1.9 


14 




2 







2 


4 


6.9 


4.1 


15 


2 




9 




2 


2 


3.1 


1.3 


16 




4 


2 


4 


6 


2 


4.7 


1.7 


17 




7 


2 


2 


7 


7 


3.0 


1.2 


18 




2 


5 


5 


2 


2 


3.5 


0.7 


19 


5 




9 


7 


11 


4 


5.1 


2.3 


20 


2 




7 


7 


12 


7 


4.5 


1.7 


21 




2 


7 


7 


2 


8 


7.0 


4.1 


22 


2 







2 


2 


2 


4.5 


1.7 


23 







5 


5 


7 








24 


2 




5 


7 


7 


7 


4.3 


1.5 


25 







2 


7 




2 


3.7 


0.8 


26 


4 










4 


2 


3.5 


0.7 


27 




2 





2 


2 


4 


5.5 


2.6 


28 




4 


4 


2 








4.3 


1.4 


29 


2 




2 


5 


5 


5 


1.9 


0.9 


30 


4 




9 


9 


4 


6 


4.2 


1.4 


31 


2 




2 




7 


2 


3.2 


0.1 


32 




2 


2 


4 








3.1 


0.0 


33 




4 


4 





2 








34 







11 


11 


4 








35 




2 











4 


3.2 


0.2 


36 







2 


5 


10 


2 


3.7 


0.8 


37 




4 


2 




6 


2 


6.6 


3.6 


38 


2 




12 


4 


7 





3.6 


0.8 


39 


4 






4 


4 





3.5 


0.7 


40 


2 




5 












41 


2 




4 


8 


10 


8 


4.7 


1.8 


42 




4 





2 


4 





4.4 


1.2 


43 







3 


5 


2 





1.9 


1.1 


44 







8 


10 


4 


8 


6.5 


3.4 


45 




2 





2 





4 


4.7 


1.9 


46 




4 


2 


2 







3.9 


0.9 


47 


2 




2 


6 


2 


6 


4.8 


1.7 


Av. 




.826 


2.50 


3.21 


2.79 


2.17 


4.16 


1.3 


<T 


3 


.191 


3.864 


4.048 


4.289 


3 . 433 


1.248 


1.234 


P.E. 




.3158 


.3941 


.4372 


.4418 


.3570 


.1297 


.1283 



126 



HEALTH EDUCATION 



TABLE II 

Percentage Underweight op February Groups 
Nutrition Group 













Total Gain 






February 


April 


June 




(lbs.) 


Normal Gain 


No. 


+ 


+ 


+ 


- 


+ 


+ 


1 


8 


4 




8 


1.0 


0.1 


2 


22 


16 




20 


0.4 


0.7 


3 


7 


12 




8 


1.5 


0.4 


4 


10 


5 




10 


0.5 


0.7 


5 


10 


3 




10 


0.2 


0.9 


fi 


11 


7 




4 


0.8 


0.3 


7 


10 


6 






0.8 


0.3 


8 


7 


9 




9 


0.4 


0.7 


9 


8 


8 




6 


0.3 


0.8 


in 


14 






15 


0.3 


0.8 


n 


11 


7 




9 


1.0 


0.1 


12 


10 






12 


0.9 


0.2 


13 


10 


10 




12 


0.0 


1.3 


14 


22 


20 




20 


0.3 


1.4 


Av 


-11.43 


-8.92 


-11. 




0.5 


-0.564 




4.651 


4.780 


4. 


657 


.5154 


.4748 


P.E. 


.8372 


.9321 




8708 


.0927 


.0854 



Control Group 



1 


4 


2 


2 






0.5 


1.9 


2 




» 




7 


1.2 




02 


3 


2 


2 









1.1 


2.5 


4 


2 


2 




7 




1.0 


2.4 


5 





4 







0.3 




1.1 


6 





2 






2.3 




0.9 


7 





4 







1.3 




0.1 


8 


2 














9 


4 


2 




6 




1.4 


2.8 


10 




2 




2 


0.5 




0.9 


11 





2 




2 


3.7 




2.3 


12 


2 


4 




2 


0.4 




1.0 


13 


2 


2 




8 




1.5 


3.2 


14 


2 


2 






0.8 




0.6 


15 


4 


4 









1.3 


2.7 


16 


4 


2 






0.8 




0.6 


17 


2 


2 




10 




0.2 


1.6 


18 




2 




2 


0.8 




0.8 


19 





2 




4 




1.0 


2.4 


20 




4 




8 




1.8 


3.2 


21 


2 


2 






0.9 




0.5 


22 


2 






2 




0.4 


1.8 


Av. 


1.00 


1.05 




3.41 





133 


-1.29 


a 


2.134 


2.460 




3.466 


1 


341 


1.356 


P.E. 


.3393 


.3813 




.5684 




1871 


.1993 



GROWTH IN WEIGHT AND HEIGHT 127 

lbs. with a range from 1.4 to 6.3 lbs. ; moreover the 
average deviation from normal gain is a slightly 
positive one, 0.769 lb. For the Control Group the 
average gain in weight is 4.16 lbs. with an average 
deviation from normal gain of 1.3. 

The Probable Error of Difference between the 
total gains of the groups is 0.2022, the Difference 
being 2.324 times this Probable Error. 

The Probable Error of Difference between the 
average deviations from normal of these groups is 
0.1963, the Difference being 2.705 times this Probable 
Error. 

SEASONAL VAKIATION" 

Chart 2 is a graphic representation of the aver- 
ages in Tables la, lb, and II, including an aver- 
age obtained for September, 1920, after the sum- 
mer vacation. The upward trend of the curve indi- 
cates a decrease in the percentage underweight, the 
downward trend, an increase in this percentage. It 
can be seen that the September Nutrition Group 
shows a marked rise in its curve from October to 
April, which is indicative of a rapid reduction 
in its percentage underweight, a reduction from 
11.56% ±2.691 underweight in October to 4.4% 
±3.217 in April; the greatest percentage of gain 
occurred before December. This is followed from 
April through the following September by a drop 
in the curve or an increase in percentage under- 
weight; in June this was 6.54% and in September, 
1920, 8.4%. 

The Control Group Curve for percentage under- 



128 



HEALTH EDUCATION 



OCT DEC. FEB. ATT*. J y NE AU& OCT. 



?e*CEN1J 

4 



NUTRITION 



SETT 




SEPT.. 



Chart 2 
Percentage Underweight 1 — First Grade 



GROWTH IN WEIGHT AND HEIGHT 129 

weight follows the same general trend except that 
its fluctuations are smaller. Starting at 0.83% 
underweight in October, it rises rapidly to 2.5% 
overweight in December. In February it reaches its 
highest point, 3.21% overweight, after which there 
is a decline through April, June and September, 
when the group is 2.17% overweight. 

The similarity between all four of the curves in 
Chart 2 is striking, the exception being that the Sep- 
tember Control Group reaches its highest point in 
February instead of April, as is the case for the 
other groups. 

The averages for height and weight contained in 
Table III are plotted in Chart 3, together with curves 
of growth in weight according to the Thomas D. 
Wood norms * and the Porter norms f as indicated 
by the dotted line. The similarity between these 
normal curves and that of the Control Group estab- 
lishes the value of the latter as a control. 

The Weight Curves of the Nutrition and Control 
Groups while alike in trend are widely different in 
placement on the weight scale ; there is a difference 
of 4.99 lbs. in the October measures and a difference 
of 5 lbs. the following September. The largest in- 
crease for both groups occurs between October and 
February ; from February to June there is a marked 
decrease in rate of gain and a still further decrease 
between June and September. The following figures 
indicate these fluctuations in percentages: 

* See Wood tables of height and weight published in the pamphlet 
by Dr. L. Emmett Holt, Standards of Nutrition and Growth, Child 
Health Organization, New York City. 

t Op. cit. 



130 



HEALTH EDUCATION 



oct L agft A e tB APt JuNE 




Chart 3 

Curves of Growth in Height and Weight for September Nu- 
trition and Control Groups, Also the Normal Weight Curves 
of Wood and Porter, 



GROWTH IN WEIGHT AND HEIGHT 131 

Gain in Weight 



Total Oct -Oct. 
Oct.-Feb. 
Feb -June 
June-Sept 



September Nutrition 



5.62 lbs. 

3.63 lbs. or 64.6% 
1.02 lbs. or 18.1% 
0.97 1b. or 17.3% 



September Control 



5.41 lbs. 

2.57 lbs. or 47.5% 
1.55 lbs. or 28.7% 
1.29 lbs. or 23.8% 



The curves of growth in height show a similar 
trend for both groups and their initial points as well 
as their final points are close together. Both show 
little increase between October and February; from 
February through June and September there is an 
approximately constant rate of growth, the Control 
Group gaining more from February to June than 
from June to September, and the Nutrition gaining 
more from June to September than from February 
to June. Rate of increase in height is apparently 
not affected to any extent by the percentages of 
underweight we are considering. The percentages 
of growth in height are as follows : 

Gain in Height 



September Nutrition 



September Control 



Total Oct .-Sept. 
Oct.-Feb. 
Feb -June 
June-Sept 



2.24 ins. 

0.57 in. or 25.4% 
0.81 in. or 36.2% 
0.86 in. or 38.4% 



2.13 ins. 

0.30 in. or 14.1% 
1.03 ins. or 48.3% 
0.8 in. or 37.6% 



Chart 4 contains individual curves for growth in 
height and the composite curve for the September 
Nutrition Group. Only those individuals have been 



132 



HEALTH EDUCATION 



TABLE III 
Monthly Measurements op First Grade Pupils 1919-20 



September Nutrition Group 



No. of 
Cases 



Aver- 
age 



September Control Group 



P.E. 



No. of 

Cases 



Aver- 
age 



P.E. 



October: 

Wt., lbs. . 

Ht., ins. . 
November: 

Wt., lbs. . 

Ht., ins. . 
December: 

Wt., lbs. . 

Ht., ins. . 
January: 

Wt., lbs.. 

Ht., ins. . 
February: 

Wt., lbs. . 

Ht., ins. . 
March: 

Wt., lbs. . 

Ht., ins. . 
April: 

Wt., lbs.. 

Ht., ins. . 
May: 

Wt., lbs. . 

Ht., ins. . . 
June: 

Wt., lbs. . 

Ht., ins. . , 
October: 

Wt., lbs.., 

Ht., ins . . , 



44 
44 

33 
35 

36 
36 

37 
35 

31 
31 

36 
36 

38 

28 

33 
34 

36 
35 

37 

37 



39.32 
43.35 

40.74 
43.36 

41.81 
43.71 

42.04 
43.56 

42.32 
43.84 

43.01 
44.05 

43.73 
44.35 

44.25 
44.39 

43.88 
44.67 

44.72 
45.69 



3.371 
1.703 

3.260 
1.559 

4.499 
1.730 

3.637 
1.657 

3.454 
1.755 

3.943 
1.894 

4.182 
1.798 

4.340 
1.985 

4.331 
1.918 

4.319 
2.058 



.3438 
.1737 

.3814 
.1777 

.5038 
.1937 

.4037 

.1888 

.4179 
.2123 

.4416 
.2121 

.4558 
.2283 

.5077 
.2302 

.4850 
.2186 

.4794 

.2284 



47 
47 



44 
44 



39 
39 



43 
43 



42 
42 

41 
41 



44.31 
43.66 



46.15 
43.84 



46.90 
43.96 



48.04 
44.59 



48.57 
45.04 

49.72 
45.82 



3.128 
1.602 



3.457 
1.367 



3.577 
1.438 



3.628 
1.659 



3.739 
1.584 

4.492 
1.755 



.3065 
.1569 



.3526 
.1394 



.3863 
.1553 



.3736 
.1708 



.3888 
.1647 

.4716 
.1842 



GROWTH IN WEIGHT AND HEIGHT 133 




Chart 4 
Curves of Growth in Height 



Individual 
Composite 



134 HEALTH EDUCATION 

included who had sufficient measurements to make 
comparable curves. 

Their significance lies in the similarity between 
the individual rates of growth in height with but 
little deviation from the trend of the composite 
curve, 

RELATIVE GAINS AND VARYING DEGREES OF UNDERWEIGHT 

In order to throw some light upon the variation 
in growth within the Nutrition Group, we have sub- 
divided it into three sections ; one is made up of the 
children 8 and 9% underweight (Section 1), another 
of the children 10-12% underweight (Section 2), and 
a third of the children 13-20% underweight (Section 
3). These sections contain 8, 20, and 9 cases respect- 
ively, the first and third each comprising approxi- 
mately 25% of the entire group. Only those children 
are included for whom we had weighings in October, 
February, and June. 

In Chart 5, we have plotted the averages for these 
sections; it is evident that there is a close corre- 
spondence between Section 2 and Section 3 both in 
their initial measurements and in gains in weight 
during the time of the Nutrition Class. Starting 
at 39.3 lbs. and 38.6 lbs. respectively in October, they 
are 41.4 and 41.6 in February, and 42.2 and 42.4 in 
June. Section 2 gains 3.8 lbs. in the 8 months 
period; Section 3 gains 2.9 lbs. The expected gain 
for children of this age and height according to 
Wood is 3.2; according to Porter, who has consid- 
ered seasonal variation, 4.2 lbs. Considering Sec- 
tion 1, we find the average weight in October to be 
nearly 5 lbs. higher than that for the other Sections. 



GROWTH IN WEIGHT AND HEIGHT 135 





Chart 5 
Gain in Weight of Sections in First Grade Nutrition. Class. 



136 



HEALTH EDUCATION 



The curve of growth also shows a more rapid rise 
and a total gain of 5.0 lbs, or more than the expected 
gain. 

The averages of the Control Group for the same 
months are much like those of Section 1. 



Average Weight in Pounds 





October 


February 


June 


Total Gain 


Section 1 


44.3 
43.8 


46.9 
47.2 


48.6 
48.8 


4.3 
5.0 



These results suggest that a percentage of 8 or 
9% underweight as determined by present standards 
does not materially affect the normal growth of a 
child in weight; a percentage underweight of 10 or 
more involves less absolute gain and less than the 
expected normal gain.* 

Further illustration of this point can be found in 
Chart 6. Individual curves of growth in weight by 
weekly weighings have been plotted for the five 
children in the Nutrition Group who were the least 
underweight and for the five most underweight. 
Those in the first group were all 8%, the second 
ranged from 15-20% underweight. Composite 
curves from the averages have also been plotted for 
each of these divisions. 

The 8% underweights group themselves closely 
together and follow the same trend. The initial 
measures of the individual curves lie between 44 and 

* Benedict, F. G., Miles, W. R., Roth, P., and Smith, H. M. Pub- 
lication No. 280, Carnegie Institution of Washington. — The percent- 
age underweight of fasting men related to the lowering of basal 
metabolism is noted. 



GROWTH IN WEIGHT AND HEIGHT 137 



fOUNDS 
St. 




Chaet 6 

September Nutrition Group 

Gain in Weight According to Weekly Weighings. 



138 HEALTH EDUCATION 

48 lbs., the final measures between 48.4 and 53 lbs., 
the ranges for both being 4 and 4.6 lbs. respectively. 
The average gain shown in the composite cnrve is 
4.9 lbs. in comparison with 3.2 lbs., the expected gain 
according to tables of Wood.* 

The gain of those most underweight is not so 
consistent; this would be expected from the wider 
range of underweightness. This group ranges in 
initial measurement from 36.1 to 41.4 lbs., the varia- 
tion being 5.3 lbs. ; in final measurement it ranges 
from 38.2 to 47.7 lbs., the variation being 9.5 lbs. 
The average gain shown in the composite curve is 
3.5 lbs., or 1.5 lbs. less than the least underweight 
division. 

Three individual curves are closely allied, varia- 
tions being limited to approximately 1 lb. Of the 
remaining curves, one is for an individual 17% 
underweight, whose curve shows many fluctuations 
and whose gain in weight for the whole year is only 
2.1 lbs. The other curve is for the individual who 
is the most underweight of the whole September 
Group and who shows a larger gain than anyone else 
in the. entire group. 

VAEIATIOISrS I1ST TYPE 

The following cases illustrate variations in type 
of undernourished child : 

A. 20% underweight in October, 9% underweight a 
year later. 

In General Intelligence bright by the two Scales 
and Performance Tests. 

In Highest Rank by Teacher's Rating. 

* In computing this expected gain we have referred in Wood 's table 
to the height and age of the Nutrition Group. 



GROWTH IN WEIGHT AND HEIGHT 139 

Motor Control. — In precision of movement and 
coordination not involving great expenditure of mus- 
cular energy, very good. 

In control of involuntary movements and in 
fatigue index shown by decrease of output in contin- 
uous movements, he is considerably below the aver- 
age of the group. There are evidences of emotional 
instability both from the objective evaluation of 
Questions and Dark Eoom Scores and from the types 
of responses. 

He has various fears : of the dark, of loud noises, 
of crossing a bridge over water, of trying to swim, 
is ill from riding in a subway or from sight of blood, 
and does not stand pain quietly. He has no tremors 
or twitches; does not stutter. It would seem from 
the picture a case of bad adjustment habits to be 
overcome primarily by an analysis of these and a 
reconstruction from the viewpoint of conscious con- 
trol either on the part of child or parent in the for- 
mation of new habits. This involves a motivation 
which in this case seems to have been secured by 
the social contact with the mother which gave her 
an appreciation of the needs of her child, whom she 
puts above other interests. Also the child himself 
was clever enough and sensitive enough in his re- 
sponses to make new adaptations. 
B. 17% underweight in October, 16% underweight 
a year later. 

In General Intelligence he is in the low normal 
grouping and is rated medium by his teacher. In 
Performance Tests he is quick in reaction time but 
only fairly accurate. In Motor Control he is not up 
to the average of the group either in rate of simple 



140 HEALTH EDUCATION 

discriminative movements or in control of invol- 
untary movements. He shows little fatigue in mus- 
cular expenditure, but his early efforts are so far 
below the average there is not a comparable output, 
though a low threshold of fatigue is indicated. His 
ability to profit by experience is fair, and the time 
and accuracy of association responses are about the 
average of the group. He shows few signs of emo- 
tional instability. 

The environment seems to induce faulty habits of 
living which make for a low state of physical well- 
being that has probably been chronic for years. 
Other children in family are reported as much under- 
weight as he. 

In Chart 7 we have plotted the curves of growth 
in weight for those cases that seem to be chronic 
underweights, showing but little actual gain. 

FAMILY CHARACTERISTICS 

In order to obtain some information concerning 
the relationship between the percentage underweight 
of the child and of his parents, cards were sent to 
the various homes asking that the weights and 
heights of the members of the family be recorded. 
Wherever possible these were checked up by meas- 
urements made in the school clinic. In this way 
accurate averages have been obtained for 23 of the 
mothers, but the fathers' averages are based for the 
most part on information given by them. 

The average age for the mothers is 34.9 years, 
with a range from 26 to 45 years; for the fathers, 
39.1 years, with a range from 28 to 56 years. 



GROWTH IN WEIGHT AND HEIGHT 141 



iPOUNSS 

45 




3* 



Chart 7 



Curves op Growth in Weight from September to June op Se- 
lected Individuals Showing only Slight Increase. 



142 



HEALTH EDUCATION 





No. of Cases 


Average 


<T 


Mothers' weight . . . 


34 
31 
26 
21 


138.11 lbs. 

59.74 ins. 
149.29 lbs. 

61 . 60 ins. 


22.715 


Mothers' height 


3.523 


Fathers' weight 


19 . 149 


Fathers' height 


2.886 







The above averages have been compared with the 
norms of the Metropolitan Life Insurance Company 
of weight for a given age and height. Accordingly 
the mothers are 5% overweight and the fathers 12% 
overweight. We note that' the parents are low in 
stature compared with the average for adults. 

A correlation of .126 has been obtained between 
the percentage underweight of the child at his first 
weighing and the weight of the mother. Although 
not significant there is a slight tendency in this group 
for the most underweight children to have the 
heaviest mothers. 

Fifth Grade Group 

The boys of the fifth grade Nutrition Class formed 
in September, 1918, were also measured monthly 
from September, 1919, to June, 1920, and again in 
September, 1920. Their Control Group was meas- 
ured in February and in June, the October measures 
being omitted through error in the organization of 
the program. 



DISTRIBUTION OF PERCENTAGES OVER AND UNDERWEIGHT 

Chart 8 represents the distribution of the percent- 
ages over and underweight for the entire fifth grade 



GROWTH IN WEIGHT AND HEIGHT 143 




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144 



HEALTH EDUCATION 



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GROWTH IN WEIGHT AND HEIGHT 145 

entrants in September, 1918. Of 223 individuals in 
the grade, 39, ranging from 7-20% underweight, 
formed the fifth grade Nutrition Group and 38 in- 
dividuals, ranging from 3% over to 3% under formed 
the Control. The Nutrition Group averaged 9.69% 
±2.873, the Control, 0.632% ±1.952 underweight. 

Considering the entire grade, we find 22 individ- 
uals are of normal weight for height, and 53 or 26.3% 
are 7% or more underweight; 31 or 15.4% are 7% 
or more overweight; 2 or 1.1% are over 15% under- 
weight, 3 or 1.7% are over 15% overweight, one 
reaching 52% overweight. 

Chart 9 shows the distribution of the fifth grade 
Nutrition Group when it was originally selected and 
of the same group in September, 1919. The chrono- 
logical age of this group ranged from 9.7 to 14.4 
years with an average of 11.2 years. The average 
percentage underweight in September, 1918, had 
been reduced from 9.69% ±2.873 to 7.73% ±4.146 in 
September, 1919; the range which had been 7-20% 
under became 1% over to 16% under. The Probable 
Error of Difference between the percentages is 
0.5583, the actual difference being 3.510 times this 
Probable Error, which shows significant gains. 

In 1918 and again in 1919 there were 8 individuals 
12% or more underweight. In spite of this simi- 
larity in the high percentages underweight, we find 
the low and medium percentages grouping them- 
selves more closely around the normal point; while 
in 1918 no children were less than 7% underweight, 
in 1919 we find 14 who are less than 7%, 4 of whom 
are within the Control Group limits. 



146 



HEALTH EDUCATION 



COMPARATIVE GAIN'S AND SEASONAL VARIATION" 

Table IV shows the variations in the percentages 
underweight throughout the two-year period which 
are plotted in Chart 10. The decrease in percentage 
from October to February is again noted. It is 
especially significant that this group makes a grad- 
ual but consistent reduction, bringing itself accord- 
ing to group average to a normal standard by Oc- 
tober, 1920. 

In Chart 11 we have plotted the growth in weight 
and height for the fifth grade Nutrition and Control 
Groups together with the Porter and Wood norms. 
Averages are taken from Table V. 

The weight curves for these groups are much alike, 
the gains in weight from October, 1918, to June, 
1920, being 12.64 lbs. for the Nutrition Group and 
12.11 lbs. for the Control. It is interesting to note 
the fact that the Control is approximately 1.3 inches 
shorter than the Nutrition Group. 

The average gain in weight of our Nutrition Group 
slightly exceeds the norms of Wood and Porter, 
although in actual weight the latter norms are con- 
siderably higher than ours. 



Gain in Pounds 





1918-1919 


1919-1920 


1918-1920 


Nutrition 


8.03 
7.00 
5.50 


8.37 
7.00 
8.00 


16 4 


Wood 


14 


Porter 


13 5 







GROWTH IN WEIGHT AND HEIGHT 147 






I; 



h(9 



o J e* 




148 



HEALTH EDUCATION 



m w nt 



ww m oer. us jn» m*' mt 




Chart 11 

CusvEa of Growth in Height and Weight, Fifth Grade Nu- 
trition and Control Groups 



GROWTH IN WEIGHT AND HEIGHT 149 



TABLE IV 

Percentage Underweight 
Fifth Grade 





Nutrition 


Control 




No. 
of 

Cases 


Average 

% 
Under- 
weight 


a 


No. 

of 

Cases 


Average 

% 
Under- 
weight 


a 


October, 1918 
November, 1918 . . . 
June, 1919 

October, 1919 
December, 1919 . . . 
February, 1920.... 

April, 1920 

June, 1920 

September, 1920... 


39 
41 
38 

37 
38 
36 
34 
34 
31 


9.69 
7.02 
6.76 

7.729 
5.144 
5.525 
4.176 
6.264 
6.419 


2.873 
3.412 
4.366 

4.146 
4.584 
5.296 
4.749 
5.002 
5.296 


38 
25 

27 

25 
25 


0.632 
+0.72 
1.11 

+0.32 
+0.60 


1.952 
3.954 
3.457 

4.805 
4.808 



150 



HEALTH EDUCATION 



TABLE V 

Monthly Measurements of Fifth Grade Pupils, 1918-20 







Nutrition Group 


Control Group 




No. 
of 

Cases 


Aver- 
age 


a 


No. 

of 

Cases 


Aver- 
age 


a 


Oct., 


1918— Weight, lbs.. 


39 


64.82 


8.140 


38 


66.54 


8.307 




Height, in . . . 


39 


53.72 


2.721 


38 


52.47 


2.678 


Nov., 


1918— Weight, lbs.. 


41 


66.74 


8.745 










Height, in . . . 


41 


53.70 


2.693 








Dec, 


1918— Weight, lbs.. 


38 


67.89 


9.190 


25 


66.20 


7.574 




Height, in . . . 








25 


52.02 


2.527 


Feb., 


1919— Weight, lbs.. 
Height, in . . . 


42 


68.82 


9.890 








April, 


1919— Weight, lbs.. 
Height, in. . . 


42 


69.23 


9.126 








June, 


1919— Weight, lbs.. 


40 


69.11 


9.558 


27 


68.17 


8.303 




Height, in . . . 


38 


54.50 


2.905 


27 


53.07 


2.568 


Oct., 


1919— Weight, lbs.. 


37 


71.16 


10.506 










Height, in . . . 


37 


55.36 


3.193 








Nov., 


1919— Weight, lbs.. 
Height, in . . . 


36 


72.19 


10.699 








Dec, 


1919— Weight, lbs . . 


38 


74.70 


12.069 










Height, in . . . 


35 


56.00 


3.324 








Jan., 


1920— Weight, lbs. . 


38 


74.17 


11.330 










Height, in. . . 


38 


55.69 


3.086 








Feb., 


1920— Weight, lbs.. 


37 


73.96 


9.664 


26 


76.15 


9.373 




Height, in . . . 


37 


55.53 


2.905 


26 


55.02 


2.635 


March 


1920— Weight, lbs . . 


36 


74.87 


11.868 










Height, in . . . 


36 


56.01 


3.164 








April, 


1920— Weight, lbs.. 


35 


74.85 


10.431 










Height, in . . . 


35 


55.91 


2.800 








May, 


1920— Weight, lbs . . 


35 


77.89 


13.325 










Height, in. . . 


36 


56.44 


3.322 








June, 


1920— Weight, lbs... 


34 


77.46 


12.881 


25 


78.65 


9.861 




Height, in . . . 


34 


56.81 


3.478 


25 


55.79 


2.677 


Oct., 


1920— Weight, lbs. . . 


30 


78.30 


10.574 










Height, in. . . 


30 


75.25 


3.033 









GROWTH IN WEIGHT AND HEIGHT 151 

The percentages which follow show gains made 
in periods of four months by the Nutrition Group. 

Fifth Grade Nutrition Group 
Gain in Weight 





No. 




No. 






of 


1918 


of 


1919 




Cases 




Cases 




Oct-Oct. 




8.03 lbs. or 100% 




8.37 lbs. or 100% 


Oct -Feb. 


38 


4.64 lbs. or 57.8% 


36 


3.58 lbs. or 42.8% 


Feb -June 


38 


1.58 lbs. or 19.7% 


33 


2.3 lbs. or 27.5% 


June-Oct. 


36 


1.81 lbs. or 22.5% 


29 


2.49 lbs. or 29.7% 



Gain in Height 



Oct-Oct. 




2.08 ins. or 100% 




2.12 in. or 100% 


Oct -Feb. 
Feb -June 


} 


1.35 ins. or 64.9% 




0.32 in. or 15.1% 
0.97 in. or 45.8% 


June-Oct. 




0.73 in. or 35.1% 




0.83 in. or 39.1% 



Here again the greater increase in weight can be 
noted from October to February. From February 
to June we again have a reduction in rate of growth, 
but in 1918-19 it is a very pronounced one, due in 
a measure to the fact that 13 children of the group 
had tonsil operations from March to June and lost 
an average of 3 lbs. in weight. 

KELATIVE GAIN'S AND VARYING DEGREES OF UNDERWEIGHT 

Relative gains made by groups differing in degree 
of percentage underweight are shown in Table VI. 

The two sections are formed by taking from the 
entire grouping the 22 cases who gained enough 



152 



HEALTH EDUCATION 



TABLE VI 

Percentage Underweight 
Fifth Grade Nutrition Class 





No. of Cases 


Average 

% 
Underweight 


<r 


October, 1918 

Section 1 

2 


17 

22 


11.47 
8.32 


3.311 
1.316 


November, 1918: 

Section 1 

2 


18 
23 


9.94 
4.74 


2.967 
1.386 


June, 1919: 
Section 1 


21 
17 


8.33 

4.82 


4.275 


2 


3.638 


October, 1919: 

Section 1 

2 


19 
19 


9.74 

5.84 


4.170 
3.137 


February, 1920: 

Section 1 


19 

18 


6.58 
2.11 


5.038 


2 


3.650 


June, 1920: 

Section 1 

2 


19 
19 

15 

14 


8.00 
4.42 

7.73 
5.93 


5.026 
3.775 


September, 1920: 

Section 1 


4.828 


2 


5.402 







GROWTH IN WEIGHT AND HEIGHT 153 



Gain in Weight 
1918-1919 





No. 






No. 








of 


Section 1 


of 


Section 2 




Cases 






Cases 






Oct-Oct. 




6.83 lbs. 


or 100% 




9.01 lbs. 


or 100% 


Oct.-Feb. 


17 


3.5 lbs. 


or 51.2% 


21 


5.57 lbs. 


or 61.8% 


Feb -June 


20 


1.78 lbs. 


or 26.1% 


18 


1.36 lbs. 


or 15.1% 


June-Oct. 


18 


1.55 lbs. 


or 22.7% 


18 


2.08 lbs. 


or 23.1% 



1919-1920 



Oct .-Oct 




8.16 lbs. or 100% 




8.59 lbs. or 100% 


Oct.-Feb. 


18 


3.26 lbs. or 39.9% 


18 


3.89 lbs. or 45.3% 


Feb -June 


18 


2.16 lbs. or 26.5% 


15 


2.47 lbs. or 28.7% 


June-Oct. 


15 


2.74 lbs. or 33.6% 


14 


2.23 lbs. or 26% 



in the period elapsing between the original weigh- 
ing in October, 1918, and the forming of the class 
in November to bring them to a normal standard. 
These are called Section 2. While the numbers vary 
for these two groups because of additions to the 
sections throughout this period, there was no inter- 
change from one section to another. It is evident 
that at least half of this group were not under- 
nourished and that their rate of growth corre- 
sponds with the normal expectations. It is gratify- 
ing to note the gains made by Section 1 during the 
two years. They increased from 11.47% underweight 
in October, 1918, to 7.73% underweight in Septem- 
ber, 1920. 



154 



HEALTH EDUCATION 



The percentages of gain made by the two sec- 
tions are of interest because of the similarity in sea- 
sonal growth which is shown. The largest increase 
in weight occurs between October and February. 
The increase in weight for both sections compares 
favorably with Wood's and Porter's norms. 

Gain in Weight 





1918-1919 


1919-1920 


1918-1920 


Section 1 

Section 2 

Wood 


6.83 lbs. 
9.01 lbs. 
7.00 lbs. 
5.50 lbs. 


8.16 lbs. 
8.59 lbs. 
7.00 lbs. 
8.00 lbs. 


14.99 lbs. 
17.6 lbs. 
14 00 lbs 


Porter 


13.50 lbs. 



It is of interest that the most underweight section 
gains slightly more than the normal groups of Porter 
and Wood for the two-year period. 



Interpretations 

While a sampling of 207 Hebrew boys, 79y 2 % of 
whom are of Austrian or of Eussian parentage with 
homes in New York's crowded East side, may not 
be considered representative of children at large 
between the ages of five and a half and seven and 
a half years, we can compare the two first grade 
groups similarly selected for study, consider the 
variations within the groups, and summarize cer- 
tain findings as to growth in height and weight. It 
is significant that these findings are corroborated 
by the results from the measurements of the older 
boys throughout a two year period. 



GROWTH IN WEIGHT AND HEIGHT 155 

(1) A comparison of the numbers underweight 
in various school populations is not valid, aside from 
other conditioning factors, unless the measurements 
are taken at the same period of the year. There is 
a marked seasonal variation in gain in weight; the 
greatest increase both absolutely and relatively 
occurs between September and February. There is 
a more constant rate of increase in height with slight 
acceleration from February to September, inverse 
to the increase in weight. These two factors cause 
an appreciable difference in height-weight indices 
throughout a year. This was found true not only 
for the first grade children but also for those of the 
fifth and sixth grades; for the Control or approxi- 
mately normal groups as well as for the undernour- 
ished. While 25% of the February entrants to the 
first grade were found to be 7% or more under- 
weight, 50.7% of the number entering in September 
were 7% or more underweight. 

(2) The definition of malnutrition or undernour- 
ishment as a function of the height-weight-age rela- 
tionships with the acceptance of a 7% standard is 
not statistically justified. The children of the First 
Grade group who are 7, 8 and 9% underweight at 
the end of the season of minimal increase in weight 
behave as the Control Group in rate of growth and 
compare favorably with the growth records estab- 
lished as normal for a large group of children at 
large. Those who are 10% or more underweight are 
more erratic. Two types are specifically noted : the 
markedly retarded case who gains and loses irregu- 
larly and remains practically upon a level for a long 
period of time; the rapid gainer who surpasses the 



156 HEALTH EDUCATION 

normal rate but shows more fluctuations in his prog- 
ress and finally attains a normal level. For him 
environmental control works wonders. The former 
offers a distinct problem in the field of malnutrition. 
(3) The static standards, as 7% for all ages, do 
not seem justified. From this same school only 23% 
of 223 fifth grade children entering in September, 
1918, were found underweight according to this 
standard ; 50.7% of 126 first grade children entering 
in September, 1919, were found underweight. In 
February, 1918, there was not a marked difference 
in the percentage underweight of the various grades. 
The difference in percentage of gain in excess of 
normal was made more striking. The first grade 
children gained 37.5% more than the normal gain 
for the period of observation, which considerably 
exceeded the gain made by all other classes except 
the Terman group. While the factor of greater 
home control and parental cooperation largely Ac- 
counts for this record, it is probable too that it in- 
dicates a better nutritional status for the first grade. 

Summary 

The experiment of 1919-1920 proved reassuring 
in many respects. That the procedure developed for 
first grade children yielded better results than that 
previously used by us is shown by the number of 
individuals "making normal" during the period of 
instruction and by the definite reduction effected in 
the average percentage of underweight. Of the 48 
children enrolled in September, 20 or 45% had 



GROWTH IN WEIGHT AND HEIGHT 157 

reached normal weight for height in June and the 
average underweight of the class had been reduced 
from 11.56 to 6.54%. It will be evident that the 
inferior record of the smaller group enrolled in 
February, 2 children out of 10 (20%) making nor- 
mal, and the average of underweight reduced only 
from 11.46 to 11%, is perfectly in keeping with the 
general facts of our experience, that the factor of 
seasonal variation renders results in weight increase 
relatively slight during the second term of school. 

That the enlistment of effective home cooperation 
in conjunction with the earlier age period of the chil- 
dren furnishes an adequate explanation for the rel- 
ative efficiency of this third program of experiment 
will be obvious. The program of instruction was a 
slender one but was calculated to enlist the child's 
cooperation successfully. We can appreciate that 
additional school facilities for concrete experiences 
especially in food taking, selection, and preparation, 
and for additional rest and fresh air, might have 
considerably augmented the results obtained. 

The data collected on physical histories and the 
more careful physical examinations made of the chil- 
dren in this third experiment have resulted in a far 
clearer appreciation of the causal factors and of the 
conditions governing individual response than had 
been ours previously, while the detailed study of 
growth in height and weight has been clarifying to 
the entire experience. At the same time the need of 
a very considerable amount of research in respect 
to standards of growth, and in respect to causal fac- 
tors, has been made apparent. For this reason we 



158 HEALTH EDUCATION 

submit, in a subsequent chapter, some general inter- 
pretations of our experience, and recommendations 
for such further experiment as seems to us most 
obviously needed, to place both corrective work for 
malnutrition and general procedures in health edu- 
cation on a more secure scientific basis. 



CHAPTER VII 

MENTAL MEASUREMENTS OP FIRST GRADE 
CHILDREN 

Group Selection 

The formation of a Nutrition Class and a Control 
Group from the first grade entrants in September, 
1919, was determined solely by the respective per- 
centages underweight. These two groups were not 
made equivalent as to physical status, economic 
status, racial or stock differences, nor was the dis- 
tribution of percentages underweight similar with 
respect to variations from the central tendencies. 
The set-up was arranged for a comparative study 
of growth in weight and height of these groups and 
did not permit the control of such factors as given 
above. This makes unsatisfactory experimental 
conditions for direct comparison of mental traits. 

All the children in these classes were boys and 
95% of those in the Nutrition Class were Hebrews. 
The racial distribution of the two groups was ap- 
proximately the same. The Nutrition Group varied 
from 8 to 20% underweight as compared with norms, 
while the Control Group ranged from 7% under- 
weight to 5% overweight. Physical examinations 
were made of the Nutrition Group. ( See pp. 109-117. ) 
No physical examinations were made of the Control 
Group. The Nutrition Class was segregated into one 
class-room and came into direct contact with various 

159 



160 HEALTH EDUCATION 

members of the staff each week. They were also 
given milk each day. This makes for a very dif- 
ferent attitude as compared with that of the Control 
Group, who were separated in two class-rooms and 
after the first weighing and measuring had no other 
contacts preceding the mental examinations. These 
conditions seem to offer a better opportunity for an 
intensive study of a small group of undernourished 
children than for comparative records. 

It was decided to evaluate the Nutrition Class and 
the Control Group as to general intelligence rating, 
and to compare them in a few specific performances 
including a simple learning process, then to make 
a more intensive study of the types of responses 
made by the undernourished boys under varying 
forms of control. These examinations were given 
during January and February after the children had 
become accustomed to the routine class procedure. 

A series of tests was given to the children of the 
Nutrition and Control Groups in the Nature Study 
laboratory of the school, one section of which was 
screened off so that the distraction from the rabbits 
and chickens seemed negligible. Each child was 
taken individually for an examination which lasted 
approximately half an hour between the hours of 
nine and eleven in the morning. This series included 
the following tests: Card Sorting, Cancellation, 
Action- Agent, and Cylinders. 

After this series was completed the children in 
the Nutrition Group were brought to our laboratory 
in the afternoon in groups of four and five, and 
were given individually the following series of tests : 
Tapping (Single Plate), Tapping (Double Plate), 



MENTAL MEASUREMENTS 161 

Target, Steadiness, Walking Board, Substitution, 
and Ship Test. The scores for the Haggerty Mental 
Examination, the Intelligence Quotients by the 
Stanford Eevision of the Binet-Simon Scale, and the 
teacher's ratings were obtained from the school 
authorities. The Haggerty tests were given under 
the auspices of the Bureau of Beference and Re- 
search of the New York City school system, under 
the direction of Mr. J. L. Stenquist. The Stanford 
Revision examinations were given by Miss Elisabeth 
Irwin, the school psychologist, and the teacher's 
marks were obtained from Miss Louise Specht, as- 
sistant principal of the school. The tests given in 
the laboratory were selected for the purpose of meas- 
uring the rapidity and accuracy of responses in vary- 
ing performances with special reference to fatigue 
and practice effects. 

Apparatus and Procedure 

Slight variations from the standard test proce- 
dures were made where it seemed necessary for a 
complete understanding of the requirements by six- 
year old subjects. 

Card Sorting. — The method followed was that 
given in the Monograph by Woolley and Fischer, 
"Mental and Physical Measurements of Working 
Children," page 100, with the exception that two 
sets of 24 cards were used instead of one set of 48 
cards. The time for each of the two trials was 
recorded. 

Cancellation. — The capital A blank was used and 
the method of Woolley and Fischer (page 108) fol- 
lowed, except that when the examiner showed the 



162 HEALTH EDUCATION 

practice sheet, the subject was instructed to "mark 
out the next two A's," the examiner helping the 
child to find them and correcting any errors at once. 

Action-Agent Association Test. — The instructions 
in the Monograph "Association Tests,'' by Wood- 
worth and Wells (page 63) were followed. Only nine 
of the words listed by them were used in our series. 
The comprehension of English by these young chil- 
dren, in whose homes a foreign language is usually 
spoken, was not good enough to include all the 
words of that list. The words used were: gallops, 
bites, cuts, rings, scratches, growls, cries, stings, 
flies, ticks, shines, blows, rolls, creeps, burns. This 
list of words has been used with a number of chil- 
dren of the same age, which offers an opportunity 
for comparison of results as to reaction time and 
accuracy of response. 

Cylinders. — (Witmer.) — A description of this test, 
together with suggestions for its use, is given by 
Paschal in the Psychological Clinic, April 15, 1918, 
and by Ide in the same Journal for May 15, 1918. 
Our procedure was to set the box with the cylinders 
correctly placed before the subject with the largest 
cylinders farthest from him. The examiner said, 
"Do you see this box with the blocks fitted into it? 
Each one has its own place. " While removing the 
cylinders from the box the examiner said, "I am 
going to put them in the center and I want you to 
put them back where they belong. You may use one 
hand or both and work as fast as you can." 

The child was allowed to work as long as he 
showed indications of completing the test correctly. 
If he did not succeed at the end of five minutes, he 



MENTAL MEASUREMENTS 163 

was assisted with suggestions until all the cylinders 
were correctly placed. The time for each of three 
trials was recorded, also the number of wrongly 
placed cylinders at the end of each trial. 

Rapidity of Movement of the Hand in Single Tap- 
ping. — The method of administering the test was 
that described in the Monograph by Woolley and 
Fischer (page 75) with the exception that the tap- 
ping was continued for iy 2 minutes and readings 
of the dial were taken for each half minute instead 
of for each 15 second period. The index of fatigue 
was calculated by considering the loss in the last 
30 seconds as compared with the first 30 seconds. 

Rapidity of Movement — Tapping on Double Plate. 
— This was a more complex form of movement than 
the tapping on the single plate. The plate was de- 
vised by Professor Knight Dunlap and consists of a 
black, hard rubber base, 6 inches by 3 inches, upon 
which two brass plates, 3 inches by 2y 2 inches, were 
attached, separated by a black bar 15/16 of an inch 
in width. To each brass plate there was attached a 
binding post, so that the taps for the two plates 
could be registered separately. The plates, stylus, 
and electric enumerator were wired in series with 
battery, so that contact of stylus with either plate 
recorded a count in the enumerator. After subject 
had been told that he was to grasp the stylus in his 
right hand and tap first upon one plate then upon 
the other, just as rapidly as possible, the procedure 
was illustrated, and he was allowed to make a few 
taps so that he understood what was expected of 
him. He was told that he should continue tapping 
until the command to stop. The counter was 



164 HEALTH EDUCATION 

screened from his view, and the experimenter sat 
facing him. Each child stood during this perform- 
ance, and by means of a wooden platform the plate 
was adjusted according to the height of the child. 

When the command to begin was given a stop- 
watch was started. This was placed upon a stand 
by the side of the enumerator, so that the score for 
30 second periods could be recorded. We realized 
the difficulty in following two moving hands for 
making accurate records. The tapping was con- 
tinued for a minute and a half, and we believe the 
control was sufficient to give indications of fatigue 
effects. At the onset of fatigue there was a tendency 
to scrape across the dividing board from one plate 
to another, to strike the dividing board instead of 
one of the plates, to hit several times on one side 
and then several times on the other, and to stop for 
rest. If the stylus was held too loosely it sometimes 
failed to record. Holding of the stylus too tightly 
was usually accompanied by pounding. If the child 
stopped he was told to go on. If he continued to hit 
several times on one side of the plate he was told 
to "hit first one side then the other," and if the 
failure to register seemed to be due to a loose grasp, 
it was suggested that he hold the stylus more tightly. 
The rate of these young children was such that there 
was not a large probability of error in recording 
the score for the different periods. 

The Target Test. — This apparatus and the pro- 
cedure for conducting this test were described by 
Johnson in the Psychological Review for July, 1919, 
"Practice Effects in a Target Test. A Compara- 
tive Study of Groups Varying in Intelligence. " The 



MENTAL MEASUREMENTS 165 

procedure was modified in adaptation to the age of 
the children, and only thirty throws were given to 
each child in series of ten throws each, one dart 
thrown immediately after the other at a distance of 
ten feet from the target. 

The Steadiness Test. — The procedure followed 
was that described in the Monograph by Woolley 
and Fischer, "Mental and Physical Measurements 
of Working Children" (page 63), with the following 
modifications: instead of seating the child, he was 
standing, and the adjustments for individual heights 
were made by means of a wooden platform upon 
which he stood ; instead of beginning with the fourth 
hole for these yonng children we began with the 
first hole, taking as an arbitrary limit that hole in 
which not more than twelve contacts were made. 
Scores were recorded in terms of the hole reached 
and the number of contacts made. 

The Walking Board. — This board was devised for 
the purpose of getting at some measure of general 
bodily control, and consisted of a piece of hard wood, 
6 feet long, 2% inches wide, and 2y 2 inches thick. 
The upper side of the board had a half inch rounded 
off on either edge. This board was securely fas- 
tened upon wooden end supports which raised it 
from the floor a distance of 5 inches to the level of 
the upper side, and had the appearance of a rail. 
This rail was divided into four equal parts by means 
of cylindrical insets having a base 1% inches in 
diameter. These divisions were called I, II, III, IV. 

The subject was asked to walk from one end to 
the other without stepping off if possible, and was 
told that if he did step off to step back on again 



166 HEALTH EDUCATION 

and continue to the other end. This was done for 
three times in succession. Scores were kept of the 
number of steps off in each division and for each 
trial. In the tables only the total scores for these 
three trials are given. 

Substitution. — (Woodworth & Wells.) The first 
half of the Woodworth & Wells blank was used 
with the instructions given in Mrs. Woolley's study. 
Slight changes were necessary because of the pres- 
ence of the key at the top of the blank instead of 
on a separate card. The child was allowed to fill in 
the first two figures with the examiner's assistance. 
When the fifth line was reached the key and the first 
four lines were covered up and the child told to 
"do it from memory." 

The Ship Test. — This test is described by Pintner 
and Patterson in "A Scale of Performance Tests," 
(page 58). Their method of giving the test was fol- 
lowed. 

Dark Room Experiment. — A number of these chil- 
dren gave evidence of emotional instability and of 
fear of the dark, so a form of getting some object- 
ive measure of reactions to remaining in a dark 
room was attempted. The steadiness plate, used in 
the test of control of involuntary movements, a 
kymograph, Jaquet time marker, and an electric 
marker were wired in series with a battery so that 
contact of a stylus resting upon subject's hand was 
recorded upon a smoked paper on a revolving drum. 
The subject was seated by a table and his arm was 
placed upon a resting board so that the entire length 
of the arm and hand was in contact with the board. 
The hand was allowed to rest easily with the fingers 



MENTAL MEASUREMENTS 167 

extended forward, touching each other. On the back 
of his hand, so that it fell in the groove between the 
forefinger and the second finger, the stylus was 
placed. The steadiness plate was arranged at the 
end of this board so that hole 4 in the upper row, 
which was 12/64 of an inch in diameter, was in a 
vertical plane in such position that the stylus, rest- 
ing lightly upon the fingers, extended for a distance 
of approximately a quarter of an inch through the 
center of the hole. 

The light was turned on in the dark room while 
the child was adjusted to this position. He was told 
to let his hand rest there, keeping it as still as he 
could so that the~ stylus would not move, and that 
the light would be turned out for a time. He was 
assured that this would not be for very long and 
he must remain as still as he could. Then the 
marker was started, and the drum and a stopwatch 
were started simultaneously. After 15 seconds the 
light was turned out, the experimenter stepped out- 
side the door just behind her, closing it so that the 
child was left in a dark room for 45 seconds. The 
light was then turned on again and after 10 seconds 
the drum was stopped. The number of contacts 
made during the period of darkness was scored. 

Questionnaire. — The questions used were taken 
from a list, given to a number of children for obtain- 
ing information that might suggest emotional in- 
stability, that was originally developed from Wood- 
worth's list for adults based upon available ac- 
counts of symptoms ante-dating mental breakdowns 
and indicating poorly balanced emotional conditions. 
For each question one answer is assumed to be 



168 HEALTH EDUCATION 

wrong. This assumption is based upon the answers 
given by normal individuals. The score is the total 
number of wrong answers. A discussion of these 
questions is given by Franz.* A report of the pre- 
liminary study on children was made in " Un- 
graded" for January, 1920, which describes scoring 
and interpretation of data. The following questions 
were given to each child individually and the social 
investigator asked the mother the same questions as 
a check upon the child's answers in some cases and 
to secure exact information in others. The ques- 
tions were asked informally after the child had taken 
part in other experiments and was at ease. He 
seemed interested in his past experiences and his 
illustrations often gave more direct information 
than his categorical replies. 

Do you wake up frightened in the middle of the night? 
Do you ever walk in your sleep? 
Do you cry out in your sleep? 

Do you want a light in your room during the night? 
Do you have a great many bad headaches? 
Have you ever fainted away? 

Do you like to play alone better than with children? 
Do the other children let you play with them? 
Are you shy with other children? 
Did you ever run away from home? 
Did you ever get lost? 
Do you get used to new places easily? 
Do you find your way about easily? 
Do you have trouble walking in the dark? 
Are you afraid of the dark? 

Does it make you uneasy to cross a bridge over a river? 
Does it make you uneasy to go into a tunnel or subway? 
Does it make you uneasy to have to cross a wide street or open 
square? 

* Franz, S. I., Handbook of Mental Examination Methods, The 
MacMiUan Co., 1919, p. 170. 



MENTAL MEASUREMENTS 



169 



Do you have a great fear of fire? 

Did you ever have the habit of biting your finger nails? 
Did you ever have the habit of stuttering? 

Did you ever have the habit of twitching your fa«e, neck, or 
shoulders? 

Did you ever have the habit of wetting the bed? 

Have you a good appetite? 

Are you usually happy? 

Do you cry easily? 

Are you easy to get angry? 

Can you stand pain as quietly as other people do? 

Can you stand the sight of blood? 

Do you like out-door games? 

Have you a nickname? 

Do you do well in school? 

Have you any unusual fears? 

Is there any food you especially dislike? 

Do you break things often? 

Do you fight other children? 

Do you tease others? 

Teacher's Ratings. — To the marks given by the 
teacher no numerical value was assigned, but to 
facilitate computation we have used an arbitrary 
numerical value in place of the original alphabetic 
ranking. The following values were assigned to the 
school markings : 



School Work 


Mark 


Numerical Value 


Failure 


D 
C 
B 

B + 
A 


1 


Fair 


2 


Good 


3 


Very good 

Excellent 


4 
5 







170 



HEALTH EDUCATION 



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MENTAL MEASUREMENTS 



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HEALTH EDUCATION 



TABLE I 
Nutrition Group 
First Grade 





Stanford 


Haggerty 


Teacher's 


Question- 




I.Q. 


Score 


Rating 


naire 


A. B 


100 


35 


5 


7 


M.B 


87 








N.C 


87 


33 


3 


11 


B.D 


95 


30 


2 


9 


S. Fa 


126 


71 


5 


3 


J. Fa 






3 


4 


S. Fi 


100 


34 




10 


J. Fr 


102 


42 


3 


9 


N. G 


94 


21 


4 


8 


P.G 


100 


26 


4 


15 


A.G 


88 


17 


3 


11 


B. H 


88 


23 


3 


9 


I.H 


91 


33 


3 


4 


P. K 


72 




2 


5 


J. K 


104 


28 


3 


4 


A. K 


108 


47 


5 


10 


E. L 


83 


32 


5 


6 


L. Le 


105 


36 


4 


10 


J. L 


110 


33 


4 


6 


H.L 


115 


27 


4 


9 


I L 


81 
100 


17 
32 


3 
3 


12 


L. Lu 


3 


L.M 


77 


18 


3 


10 


M.M 


104 


50 


5 


5 


L. P 


92 


27 


4 


8 


J. P 


110 


74 


5 


6 


M.R 


92 








S. R 


115 


19 


3 


10 


N. R 


103 


41 


3 


10 


I. s 


77 
81 


-2 



1 

1 


8 


H. Sa 


7 


N. S 


96 






10 


D. S 


108 




5 


8 


H. Sk 


94 


15 


2 


11 


M. T 


93 


51 


5 


5 


H. U 


100 


47 


4 


4 


N. W 


90 


37 


3 


11 


J. Y 


64 


38 


3 


6 


No. of cases. . 


37 


32 


34 


36 


Average 


95.46 


32.25 


3.47 


7.89 


a 


12.74 
1.414 


16.09 
1.915 


1.12 

0.1299 


2.84 


P.E 


0.318 



MENTAL MEASUREMENTS 



173 



TABLE II 

Control Group 

First Grade 





Stanford 

Revision 

I.Q. 


Haggerty 
Score 


Teacher's 
Rating 


MB 


100 


17 


3 


S.B 


104 


37 


3 


W. B 


102 


33 


3 


J.B 


75 




3 


J. C 


112 


53 


5 


L. D 


93 


22 


5 


A. F 


92 


16 


3 


B.G 


106 






A. Gl 


86 


15 


3 


G. G 


100 


34 


3 


A. Go 


89 


20 


4 


S.H 


111 


34 


4 


D. H 


92 


35 


3 


S. Je 


87 


35 


3 


S. Ju 


108 


31 


4 


A.K 


125 


35 


3 


M.L 


109 






F. L 


84 


10 


2 


L. P 


102 


28 


3 


LP 


101 


38 


4 


A. P 


79 


12 


2 


F. P 


109 


38 


3 


W. S 


88 


45 


3 


H. Sc 


107 


37 


4 


M. Sche 


84 


13 


2 


S. Schn 


84 






S. Schu 


73 




4 


B.S 


94 


31 


3 


M. Schw 


61 




1 


M. St 


100 


33 


3 


H. St 


94 


15 


4 


J. S 


55 




1 


H. T 


90 


28 


3 


J. V 


85 


41 


2 


J. Z 


92 


33 


3 


No. of cases 


35 


28 


32 


Average 


93.5 


29.25 


3.09 




14.3 


10.73 


0.926 


P.E 


1.63 


1.363 


0.1102 



174 



HEALTH EDUCATION 



Comparison of Nutrition and Control Groups 

Intelligence Level. — In general intelligence as 
measured by standardized scales both the under- 
nourished group and the control group have a nor- 
mal average rating. According to Terman, the 
average group of individuals at large make scores 
that give Intelligence Quotients between 91 and 110, 
when rated by the Stanford Revision of the Binet- 
Simon scale. 

Charts 12 and 13 show the distribution of scores 
in the Haggerty Mental Examination and Stanford 
Revision of Binet-Simon Intelligence Tests. 



Validity op Difference between Nutrition and Control 
Groups. 





P.E.D. 


D. 




P.E.D. 


Stanford Revision Intelligence Quotients . . . 
Haggerty Mental Examination 


2.157 
2.350 
0.1703 


0.901 
1.276 


Teacher's rating 


2.231 







The Nutrition Group has an average I. Q. of 
95.46, with a range from 64 to 126, only four fall- 
ing below 80. The Control Group has a slightly 
lower average of 93.51 with scores ranging from 55 
to 125, and five falling below 80. The scores for 
the Haggerty Mental Examinations show a similar 
difference between the two groups and are slightly 
below the normal of 35 for six year old children. 



MENTAL MEASUREMENTS 



175 



The average rating given by the teacher signifies 
good work. In each group approximately a third 
are slow, border-line cases or clearly defective. If 
the cases who have decided mental limitations as 
shown by two or three of the ratings were excluded, 
the normal range of scores would include all except 
three of each group, who might be classed as supe- 
rior. When we calculate the Probable Error of the 
differences between the averages, we find only in 
Teacher's Rating is there a difference of as much 
as twice the Probable Error. All three measure- 
ments are consistently favorable to the Nutrition 
Group, and we seem justified in the statement that 
the superiority in intelligence lies with the under- 
nourished group. 

The comparison of the gains in weight made by 
those having high Intelligence Quotients and those 
of low Intelligence Quotients shows a significant dif- 
ference in favor of the more intelligent. 

Gain in Weight 



(a) I. Q.>105... 

(b) I.Q.< 90... 

(c) Entire group. 



No. of Cases 



9 
32 



Av. in Lbs. 



4.54 
3.22 
3.69 



1.247 
1.216 
1.387 



P.E. 



0.2967 
0.2736 
0.165 



Difference between (a) and (b) is 3.271 times its 
Probable Error; (a) and (c), 2.504; (b) and (c), 
1.464. 



176 



HEALTH EDUCATION 



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MENTAL MEASUREMENTS 



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MENTAL MEASUREMENTS 



179 



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180 



HEALTH EDUCATION 



Card sorting. — The time and errors in Card Sort- 
ing were reduced in the second trial by both groups, 
but the Nutrition Group has better averages in time 
required and has fewer errors in both trials. 



Probable Error op Difference (P.E.D.) between Scores of 
the Nutrition and Control Groups 



Card Sorting 


P.E.D. 


D. 


P.E.D. 


Time— First Trial 


5.307 
2.915 
0.2557 
0.2750 


0.158 


Second Trial 


1.585 


Errors — First Trial 


2.335 


Second Trial 


1.673 







The difference between the Nutrition and Control 
Groups in time required for the first trials seems 
insignificant. More absolute improvement in rate 
is shown by the Nutrition Group on the second trial. 
The difference between the averages is much larger, 
and is 1.585 times its Probable Error. The differ- 
ence of 1.27 in average number of errors on the first 
trial is 2.335 times its Probable Error, and for the 
second trial this is only slightly less. This aggre- 
gate of differences in favor of the undernourished 
group indicates a slight superiority over the Control 
Group. 

Cylinders. — A study of the results in the Cylinder 
Test from the standpoint of the total time required 
and of the practice effects from one trial to another 
shows a more marked superiority of the undernour- 
ished group. 



MENTAL MEASUREMENTS 



181 



Probable Error of Difference (P.E.D.) between Scores of 
the Nutrition and Control Groups 



Cylinder Test 


P.E.D. 


D. 
P.E.D. 


Time — First Trial 


19.740 
16.386 
10.471 


2.051 


Second Trial 


1.276 


Third Trial 


0.829 







Probable Error of Difference between Trials 





Nutrition 




Control 


Cylinder 


P.E.D 


D. 
P.E.D. 


P.E.D. 


D. 


Test. 


P.E.D. 


T 2 -T 3 
Tx-Tz 


17.317 
14.071 
14.178 


4.464 
1.137 
6.582 


18.93 
13.42 

17.28 


5.12 
2.10 
7.24 



The time required decreases rapidly from first to 
second trials for both groups with a smaller differ- 
ence between second and third trials. There is a 
greater absolute gain for the Control Group, which 
has a much larger initial time score, but the percent- 
age of reduction shows greater improvement by the 
Nutrition Group. The differences in the learning 
process as shown by these averages are significant, 
since they are more than four times the Probable 
Error except between second and third trials. The 
differences in averages of the two groups for time 
required are not so significant, for the second and 



182 



HEALTH EDUCATION 



third trials, though the difference on first trials is 
more than twice the Probable Error, which is cer- 
tainly suggestive. 

Cancellation. — The Nutrition Group has a faster 
rate in Cancellation and makes fewer errors. 



' 


Cancellation 




P.E.D. 


D. 




P.E.D. 


Time 


13.410 

1.508 
1.748 


2.514 


Errors— First Half 


2.029 


Second Half 


1.865 







The difference in the averages of time required 
for the two groups is two and a half times the Prob- 
able Error of this difference. The difference in the 
average number of errors in the first half of the 
sheet is twice its Probable Error. The Nutrition 
Group shows no more inaccuracy in the latter half 
of the sheet than in the first half, but the Control 
Group has a slight increase in the average number 
of errors. 

Action-Agent. — In the test of controlled associa- 
tions there is but little difference between the two 
groups in accuracy. The errors for both groups 
were with a few words, as gallops, growls, stings, 
which were unknown to them. The Nutrition Group 
has a longer average reaction time. The scores 
range from 1.8 seconds to 9.8 seconds, with an aver- 
age reaction time of 4.5 seconds. This is 0.9 seconds 



MENTAL MEASUREMENTS 183 

longer than the average for the Control Group, and 
this difference is 3.378 times its Probable Error. 

There are five in the Nutrition Group with slower 
reactions than the longest reaction time for the Con- 
trol Group, two of them exceeding it by 2 seconds. 
Among these are three who had low intelligence 
scores. The longest reaction times for the Control 
Group were made by those having lowest intelligence 
scores. The inequality within the groups as to intel- 
ligence makes gronp comparison for a study of the 
undernourished child far less valuable. 

A group of 50 Italian boys of the same age range 
from another public school of New York had an 
average reaction time of 5.9 seconds for the same 
list, which is longer than that for the Nutrition 
Group. Their accuracy score was 8.44 in compari- 
son with 11.62 for the Nutrition Group. This group 
of undernourished boys makes fewer errors and has 
a quicker reaction time than a group in the same city 
having somewhat similar home conditions. We do 
not know, however, how many of the Italians were 
also underweight. 

Ship Test. — In the Ship Test the time scores in- 
clude so many variables that the average is of little 
value. Some took 6 minutes and made a very good 
score, others made a score of zero but completed it in 
a very short time. The average score of 7.26 coin- 
cides with the Pintner-Paterson norm of 7 to 8 for 
six-year-olds, so the performance of these under- 
nourished boys is considered normal. The low 
scores correlate more closely with Intelligence Quo- 
tients than with index of undernourishment. 



184 



HEALTH EDUCATION 




is 



a a 



MENTAL MEASUREMENTS 185 

Substitution. — In the Substitution Test no norms 
are available for half sheets, which seemed to be a 
desirable length to give these young children in com- 
bination with the other tests used during the period 
of time available for testing. There was wide varia- 
tion in the time scores. The last line used as a 
memory test for 31 individuals was free from errors 
in 23 cases, or 74.2% of the group; 3 or 9.6% made 
1 error; 2 or 6.5% made 2 errors; 2 or 6.5% made 
4 errors; 1 or 3.2% made 5 errors. 

We find that under conditions of work demanding 
maximal attention for the best records as to speed 
and accuracy, appreciation of relationships, and the 
control of associational responses, the group selected 
as undernourished make better scores than the Con- 
trol Group. They also show greater improvement 
in reducing the amount of time required for repeated 
performances together with a higher degree of accu- 
racy. Chart 14 shows the significance of difference 
between scores of the two groups. 

Motor Coordination of Nutrition Group 

Tapping. — In the Tapping Test on Single Plate 
there are marked individual variations as to total 
output and fatigue effects. The difference in actual 
taps between the first and third periods of 30 sec- 
onds averages 12.3 or a fatigue index of 4.3%, when 
this loss is compared with the total number of taps. 
This can not be directly compared with an index of 
fatigue determined by Gilbert for eight-year-olds, 
or by Wells for adults because of varying factors in 



186 



HEALTH EDUCATION 



TABLE V 

Nutrition Group 
First Grade 





Ship 


Substitution 




Walking 














Target 
Score 


Board 
Total 


Dark 












Room 




Time 


Score 


Time 


Errors 


Steps 
Off 


Score 




in sec. 




m sec. 








A. B 


67 


4 


274 





48 








N. C 


70 





240 


1 


45 


5 


8 


B. D 


55 


8 


690 


1 


21 


5 


25 


S. Fa 


110 


12 


604 


3 


35 


1 




J. Fa 


28 


6 


329 


1 


43 





2 


S. Fi 


45 





263 





11 


4 


14 


J. Fr 


120 


15 


612 


1 


67 


3 




N. G 


60 


8 


290 





41 





2 


P. G 


80 


8 


342 





46 


6 


20 


A. G 


40 


6 


290 





78 


1 


13 


B. H 


62 


6 


255 


2 


75 


10 


5 


I. H 


25 





295 


4 


43 


1 


10 


P. K 


57 


10 


500 


18 


25 


5 


4 


J. K 


90 


7 


435 


3 


41 


1 




A. K 


63 


8 


273 





45 


7 


20 


E. L 


80 


15 


385 


11 


11 


13 


22 


L. Le 


45 


12 


358 


4 


34 


23 


17 


J. L 


360 


13 


302 





41 


14 


4 


H. L 


150 


10 


240 


1 


57 





26 


I. L 


50 





285 


2 


48 


6 


2 


L. Lu 


85 





332 


4 


15 


6 





L. M 


133 


8 


550 


3 


49 


8 





M. M 


60 


10 


325 


3 


39 


1 





L. P 


67 


6 


315 





68 








J. P 


65 


18 


230 


1 


47 


4 


32 


M.R 


122 


18 


315 





36 


1 




S. R 


43 


5 


285 


1 


21 


5 


1 


N. R 


30 





339 





49 


3 





I.S 
















H. Sa 
















N. S 


35 


4 


306 


1 


64 


3 


6 


D. S 


85 


16 


333 


4 


29 


12 


23 


H. Sk 


50 


8 


443 


5 


72 


2 


15 


M. T 


95 


7 


212 





27 





1 


H. U 


98 





435 


1 


59 


2 





N. W 


72 


6 


311 


11 


38 





28 


J. Y 


45 





249 


5 


52 


8 





No. of cases 


35 


35 


35 


35 


35 


35 


31 


Average . . . 


78.34 


7.26 


349.8 


2.31 


43.43 


4.57 


9.68 




57.32 


5.31 


114.71 


3.95 


17.10 


4.97 


10.11 


P.E 


6.534 


0.6053 


13.077 


0.450 


1.949 


0.5668 


1.223 



MENTAL MEASUREMENTS 



187 



the procedure. The average total output for the first 
30 seconds — 99.8 taps — is 12.2 taps less than the 
score of 112 for 268 six-year-old city boys given by 
Pyle in the 1920 revision of his manual for the ex- 
amination of school children.* The loss from the 
first to the second period and from the first to the 
third period is a valid difference, being more than 
three times the Probable Error in each case. 



Probable Error of Difference between Averages for Tapping 
Single Plate 





P.E.D. 


D. 
P.E.D. 


First 30 seconds — Second 30 seconds 

Second 30 seconds — Third 30 seconds .... 
First 30 seconds — Third 30 seconds 


3.269 
3.117 
3.373 


3.319 
0.465 
3.646 



In Tapping on Double Plate the same loss is shown 
and again the differences are significant. 



Probable Error of Difference between Scores for Tapping 
Double Plate 





P.E.D. 


D. 




P.E.D. 


First 30 seconds — Second 30 seconds 

Second 30 seconds — Third 30 seconds .... 
First 30 seconds — Third 30 seconds 


2.537 
2.436 

2.522 


3.532 
0.472 
3.096 



* Miles, "W. E., Journal of Nervous and Mental Diseases, 1919. 
Eeduction in neuro-muscular activities is noted in subjects on low 
diet with loss of weight. 



188 HEALTH EDUCATION 

Six children of the same age from a private school 
averaged 138 taps in one minute or a score of 12 
more taps than the average of 126 made by the 
Nutrition Group. No other data are available for 
comparison. 

The fatigue effects as shown in the Single Tap- 
ping test were compared with the percentages under- 
weight at the time of the test, and with the gains in 
weight during the period of the Nutrition Class from 
October to June. The five cases showing most 
fatigue made an average gain of 4.42 lbs., while the 
six cases showing least fatigue made an average gain 
of 3.43 lbs. The difference between these averages 
is 1.816 times its Probable Error. 

At the time of testing seven boys in the most 
fatigued group had an average of 7.3% under- 
weight, while the six in the least fatigued group 
averaged 6.3% underweight. The difference between 
these averages is 1.15 times its Probable Error. 

The total output in the Tapping tests for Single 
and Double Plate forms was reckoned for groups 
having specific physical defects. Comparing these 
averages with those of the contrasting or normal 
group we find the differences shown in table on op- 
posite page. 

In each case those of firm muscle tone and without 
hyperactive reflexes make better averages than those 
defective in these respects. The variability is so 
great, however, the differences are of little signifi- 
cance. 

Primarily to obtain some check upon the Double 



MENTAL MEASUREMENTS 



189 





Muscle Tone 


Reflexes 


Tapping — Single Plate 


Poor 


Firm 


Hyperactive 


Not 
Hyperactive 


Number of cases 

Aver, number of taps 
in 1 h min 


10 

280 
45.15 
9.616 


9 

285.44 
52.45 
1 1 . 801 


9 

275.89 
45.75 
10.293 


26 
290.42 




63.42 


P.E 


8.371 




D. 
——— = 0.3573 
P.E.D. 


D. 


=1.0951 




P.E.D. 


Tapping — Double Plate 

Number of cases 

Aver, number of taps 
in 1 min 


10 

117.8 
24.28 
5.171 
D. 


9 

125.44 
20 . 462 
4.603 

= 1 . 103 


13 

124.54 
21.307 
3.984 
D. 


22 
126.91 




26.37 


P.E 


3.796 




=0.4307 




P.E.D. 


P.E.D. 



Form of Tapping, correlation coefficients were com- 
puted. 



Tapping— Single Plate with Double Plate r = 0.436 

Tapping — Single Plate with Intelligence Quotient r— 0.316 

Tapping — Double Plate with Intelligence Quotient r=0.204 

Target Test. — In the Target Test the boys of the 
Nutrition Group made a better score than nine chil- 
dren of same age in the private school. 



190 



HEALTH EDUCATION 



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MENTAL MEASUREMENTS 



191 



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192 


HEALTH EDUCATION 

Target Test 






Nutrition 


City and 
Country School 


Number of cases 

Average score 


34 

43.44 
17.35 
2.013 

D. 


9 

27.44 




16.92 


P.E 


3.807 






= 3.718 




P.E.D. 



These groups are too unequal for valid compari- 
son, but in these tests where no norms are estab- 
lished for children of this age indication of their 
relative performances in comparison with well- 
nourished children is of interest. In the Target Test 
they have a significant superiority. 

Walking Board. — The average number of steps off 
in walking the length of the Board was 4.57, with a 
standard deviation of 4.97. The scores of five boys 
far exceeded those of the remainder of the group. 
Without their scores the average number was 2.93 
and more nearly approaches the average score for 
five private school children of the same age, which 
was 2.6. A correlation of the scores for Walking 
Board and Steadiness (total contacts) gives r=.157, 
indicating slight relationship between the control of 
arm and finger movement and general bodily control 
for this group. 

Steadiness Test. — The control of involuntary 
movements was poor as compared with the six chil- 
dren of same age in the private school. 



MENTAL MEASUREMENTS 

Steadiness Test 



193 





Nutrition 


City and 
Country School 


Number of cases 

Average hole reached 


35 
1.23 
0.633 
0.072 

D. 
P.E.D. 

5.14 

3.6 

0.410 


6 
1.17 




0.362 


P.E 


0.1 


Average number of contacts .... 


=0.487 

3.33 
2.36 


P.E 


0.649 




D. 


= 2.356 

3.83 


Total contacts 


P.E.D. 

5.54 

4.3 

0.4904 


a 


3.39 


P.E 


0.9322 




-^- =1.623 
P.E.D. 



Dark Room. — The ability to keep the arm still 
even when supported is a variable, so that we have 
nothing more than a suggestion of the reaction to 
the dark. There is a wide range of scores, and the 
average of 9.68 with a standard deviation of 10.11 
is not representative of the group response. The 
correlation of these scores with the number of total 
contacts in the Steadiness Test is a negative one, 
r= —.161, but the correlation with the Questionnaire 
is positive, r=.321. 

Questionnaire. — The average number of wrong 
answers to the questionnaire was 7.89 and is approx- 



194 



HEALTH EDUCATION 



imately 20% of the total number of questions. A 
summary of the information derived shows the fol- 
lowing distribution of certain factors : 

Only child 2 

Fainted 1 

Afraid of dark 17 

Bites nails 10 

Stutters or stammers 2 

Twitches 1 





Favorite Games 


At School 


At 


Home 


cards 




guns 


soldiers 




hide and seek (3) 


in yard 




ball (3) 


robbers 




robbers 


circle games (2) 




checkers (3) 


tag (3) 




lion and mouse 


acting 




soldier 


cat and mouse 




basketball 


horses 




blocks 


hide and seek 




fire engine 


basketball 




school 


ball (2>> 




babies 


puss in corner 




pool 


house 




fireman 


blocks (2) 




circle game* 


bucking boy 




auto 


Fears 


Foods Disliked 



dark 17 

thunderstorm 11 

crossing bridge over water. 9 

lions , 7 

water 6 

bear 6 

robbers 4 

loud noises 6 

rat 3 

horse 5 



potatoes 5 

meat 7 

soup 5 

milk 2 

oranges 2 

apples 4 

sour apples 1 

coffee 3 

candy 4 

oatmeal 2 



MENTAL MEASUREMENTS 195 

Feaks Foods Disliked 

negro 2 barley soup 1 

noises in night 3 yellow food 1 

dog 6 tea 1 

wild dog 2 cream 1 

wild animal 2 bananas 2 

fire 5 tomato soup 1 

crossing wide street 3 beets 1 

big animals 1 cheese 1 

black animals 1 sour cream 1 

animals with big horns .... 1 cream cheese 1 

tiger 2 black fruits 1 

snake 2 canned salmon 1 

nannie goats 1 canned tomatoes 1 

Polack 1 water 1 

going in subway 2 bones 1 

automobiles 1 

cars 1 

The number of stutterers, 2, or 5.6%, is a 
much smaller percentage of the group than was 
found in a Nutrition Class with fifth grade boys the 
preceding year, when 5 out of 40, or 12y 2 %, were 
stutterers. In the entire grouping of 75 fifth grade 
boys, including both a Nutrition and a Control 
Group, there were 11, or 14.7%, who stuttered. If 
we can begin early enough with such speech defects 
we may make headway towards the prevention of 
such handicaps which occur more frequently in these 
groups than previous studies would lead one to 
expect. 

The number who bite nails, 10, or 28%, is again 
smaller than the fifth grade boys, where we found 
14, or 35%, of the Nutrition Class who had the habit 
of biting nails, and 23, or 30.6%, of the entire group. 
With these first grade children, biting of the nails 
was caused in some cases by lack of scissors. Two 



196 HEALTH EDUCATION 

boys spoke of trying knives and razors. Several 
said they would bite the nails off because the mother 
did not have time to cut them. In other cases there 
seemed to be an established habit of biting when 
restless. 

The fears of animals predominate in the naming 
of fears. In several cases the animals mentioned 
had never been seen, as lion, wild animal, but de- 
scriptions by some child who had been to Bronx 
Park of their terrifying aspects, or else stories of 
them, induced the belief that they should be afraid 
of such. We learned that rats are a real source of 
annoyance and fright in many of the homes. Rob- 
beries are frequently staged in their block and ex- 
citing descriptions are often related to them of 
actual robberies. These facts were elicited upon 
inquiry as to the causative factors of the fears. Such 
factors also apply somewhat to other fears as of 
negro, of crossing a bridge and of lightning during 
storm. They are not pathological fears but natural 
fears caused by the stimuli that have been presented. 
The fear of the dark, however induced, is a real one 
in many cases. Three boys cried during the short 
period of 45 seconds during which they were in the 
dark room and when they knew adults were just 
outside the door. References to moving pictures, 
both direct and in dreams, also in play activities, in- 
dicate another source of fears. The social investi- 
gator reported that all of the children go to the 
"movies" on an average of once a week, and one 
boy was taken by his mother three times a week. As 
a group they do not give evidence of excessive emo- 
tional instability. 



MENTAL MEASUREMENTS 197 

Summary 

We do not recognize these groups as clearly 
enough differentiated from the standpoint of mal- 
nutrition to be representative ones for comparisons 
of the mental traits of the undernourished child 
with those of well-nourished children. The Nutrition 
and Control Groups, however, are similarly selected 
and are well differentiated in the beginning as to 
height-weight indices. It is also possible with many 
of the tests made to compare the undernourished 
child with standards already established on children 
of the same ages. It is true that we do not know 
in many cases how many children are 7% or more 
underweight in the groups used for obtaining the 
norms. 

(1) In tests of general intelligence the undernour- 
ished children distribute themselves similarly to 
children of normal height-weight-age index. The 
central tendency is slightly higher than that of the 
Control Group and there are slight differences in 
variability. Children of high intelligence scores gain 
more under the Nutrition Class procedure than those 
of lower scores. 

(2) In a learning series the Nutrition Group is 
superior to the Control Group both in speed and 
accuracy. 

(3) In motor coordination and performance tests 
not involving uninterrupted expenditure of muscular 
energy such as Card Sorting, Aiming, and Dissected 
Pictures, the undernourished children make normal 
scores according to established standards and are 
superior to the Control Group. 



198 HEALTH EDUCATION 

(4) In rate of voluntary movements, both simple 
and complicated and continuous for an appreciably 
long period, the output for the first 30 seconds is less 
than that established for children of their age. 
There. is no evidence of a higher fatigue index for 
the children in the Nutrition Group who are most 
underweight at the time of the tests. 

(5) This group of undernourished boys shows 
sensitivity to emotional stimuli but not exaggerated 
responses to the extent of emotional instability. 



CHAPTER VIII 

INTERPRETATIONS AND RECOMMENDATIONS 
FOR A PROGRAM OF RESEARCH 

Standards of Groivth 

It will be evident that our ability to evaluate re- 
sults from our successive programs of experiment 
has been rendered problematical by the existing 
limitations of knowledge as to standards and laws 
of growth, and that a considerable amount of re- 
search must be completed in this field before the 
evaluation of returns from the health program can 
be placed on a scientific basis. 

Seasonal norms must be determined. Such stand- 
ards as we have are derived from measurements 
taken without regard to the factor of seasonal varia- 
tion, which in the case of one of our classes was 
found to involve no less than 64.6% of the entire 
yearly increment in the four months from September 
to February. In view of the facts established by 
Dr. Porter's investigation and sustained by our ex- 
perience, the need for seasonal norms becomes 
imperative. 

Before such norms can be determined,* further 
month to month studies on large numbers of children 
are needed to secure more definite knowledge regard- 

*Dr. Porter has already raised the question of the effect of sea- 
sonal variation on the weight and height for age of children born 
at different seasons of the year. Op. eit. 



200 HEALTH EDUCATION 

ing the periods of maximal and minimal weight in- 
crease. 

Possible climatic variation affecting seasonal 
norms in differing localities must be anticipated. 
The causal factors of seasonal variation are un- 
known. The winter season and confinement within 
doors appear to offer at least partial explanation. 
If these are causal factors, seasonal differences es- 
tablished for Boston and New York will not be paral- 
leled in places of such differing climatic character- 
istics as, for example Minneapolis, New Orleans, Los 
Angeles, Denver, and Portland, Oregon.* 

The relation of the period of minimal weight in- 
crease to vitality should be determined for its bear- 
ing on the school calendar. This is a question of 
particular importance for school procedure and 
health. Does the period of minimal weight increase 
indicate physical depression? American school tra- 
dition considers winter the period for intensive work, 
and teachers generally depend on the months inter- 
vening between the Christmas holiday and the 
Easter holiday as the recognized period for speeding 
up the learning process. It will be apparent that 
the latter part of this period overlaps the season 
when in our Northern communities at least, the chil- 
dren are passing through the yearly period of mini- 
mal increase and, possibly, of corresponding de- 
crease in vitality.! 

* Huntington, Ellsworth, Civilisation and Climate, Yale University 
Press, 1915. — Investigations of climatic influences on vitality as shown 
by industrial output are reported. See chart p. 66, where comparison 
is made with seasonal weight increase shown by tuberculosis patients 
in the Adirondack^. 

t For a discussion of this hypothesis see Huntington, Ellsworth, 
op. cit. pp. 88-89. 



A PROGRAM OF RESEARCH 201 

In this connection we may call attention to the 
slightly accelerated height increase indicated by our 
data (see p. 133) as coincident with the period of 
minimal weight increase.* Had Dr. Porter's data 
on Boston school children shown a corresponding 
acceleration in height increase at this period, the idea 
of decreased vitality might be dismissed on the as- 
sumption that increase in height is equally indicative 
of vitality, and that periods of height and weight 
increase are alternating. Previous to the publica- 
tion of his initial report, however, Dr. Porter had 
found no indication of seasonal variation in height 
increase. 

The relation of height increase to vitality and 
nutritional condition should be more definitely deter- 
mined. It is common experience that periods of 
accelerated height increase are attended by a de- 
crease in the proportion of weight for height, but 
existing standards make little allowance for a range 
of variation at such periods, or for a range of varia- 
tion in individuals of exceptional height for age. 
That exceptional height for age may constitute in it- 
self an index of better nutritional development, is a 
theory that seems sustained by the greater height 
development of the more favored economic classes 
the world over, as compared with peasantry and poor 
of the same racial stock. Schiotz f has shown that 
among Norwegian children this height superiority of 

* This is in accordance with the conclusions of Godin that growth 
takes place by alternating periods of height and weight increment. 
Godin, P., Growth During School Age, Eichard G. Badger & Co., pp. 
106-107. 

t Schiotz, Carl, The Development of Children between the Ages 
of Two and Six Years, Pedagogical Seminary, December, 1920, pp. 
371-397. 



202 HEALTH EDUCATION 

the favored classes is attained by the third year of 
life and is almost invariably attended by a compara- 
tive "emaciation" or decrease in the proportion of 
weight for height. In his opinion this condition is 
the ontcome of better nurture and is indicative of an 
accelerated total development, mental as well as 
physical. Thus it is even possible that early de- 
velopment in height due to a nutritional status above 
the average may account for a certain percentage 
of the underweight reported among children from 
well-to-do homes in this country. * 

It is probable that the percentage underweight 
which may be considered as constituting malnutri- 
tion varies at differing age periods and must be de- 
termined with special reference to such periods. 
Further studies of weight and height increase at the 
age of school entrance, at the period of the second 
dentition and at the periods of prepubertal and post 
pubertal development may modify our present static 
standards of underweight, 7% or 10%, as previous 
studies have identified the several age periods of 
growth. 

In a population of mixed racial stocks height- 
weight standards must allow a sufficient range of 
variation to provide for differing racial characteris- 
tics. The school population at P. S. 64 presents a 
good illustration of racial variation differing from 
accepted American standards. Where children of 
similar stocks and of other stocks presenting as dis- 
tinct characteristics are distributed through hetero- 

* For a discussion of height development as an index of nutri- 
ional status see Benedict and Talbot, Metabolism and Growth from 
Birth to Puberty, Publication 302, Carnegie Institution of Washing- 
ton, 1921, pp. 72-75. 



A PROGRAM OF RESEARCH 203 

geneous school populations, the significance of their 
variation from American standards is in danger of 
misinterpretation. Studies of growth with special 
reference to racial antecedents are needed before the 
necessary data as to the range of such variation can 
be determined. 

It will be evident, however, that norms derived 
from school populations where economic and social 
conditions are as inadequate as those found in the 
community surrounding P. S. 64 cannot be consid- 
ered true norms of the racial stock represented, and 
if progress in national health is to be our aim, norms 
of well-being rather than numerical averages should 
eventually be our determining standards. Some 
modifications of the earlier height-weight-age scales 
have already been made on the basis of school pop- 
ulations specially selected as representative of well- 
developed children of American parentage.* Fur- 
ther modifications in the same direction may be 
expected as the result of recent studies.! Children 
of foreign parentage no less than those of American 
stock should be held up to standards of well-being 
derived from measurements on well-developed indi- 
viduals of their own racial stocks. 

The susceptibility of the average family and racial 
standards to improvement is a fact that has yet to 
become a part of national and individual thinking. 
Even a few years, however, may bring very radical 
changes in our conceptions as to the possibilities of 
such improvement. It is, for example, by no means 

* Baldwin, Bird T., Physical Growth, and School Progress, U. S. 
Bureau of Education Bulletin, No. 10, 1914. 

t For a discussion of ' ' Normal average, and ideal states of nutri- 
tion," see Benedict and Talbot, Op. cit., p. 69. 



204 HEALTH EDUCATION 

clear how far the facts of seasonal variation uncov- 
ered by Dr. Porter must be accepted as natural laws 
of growth, and how far they may be attributed to 
inadequate environmental factors affecting the de- 
velopment of the great majority of Boston children 
of school age. Month to month studies of even a 
small group of children living under corresponding 
climatic conditions but in carefully controlled envi- 
ronmental surroundings might offer valuable sug- 
gestions in this direction. Certainly we must con- 
cede that the present scale of living in the great 
majority of homes is decidedly below the optimum 
so far as habits regarding food, fresh air and sleep 
are concerned. 

Causal Factors and Individual Response 

The importance of environment and the scale of 
living must not lead us to ignore the part played 
by other factors in causing underweight, and the sig- 
nificance these may have as determining relative suc- 
cess or failure in securing gains. It will be evident 
that the children in the groups studied by us ex- 
hibited a wide variation in their response to the 
program of treatment. While response for the indi- 
vidual was largely dependent on the circumstances 
of his environment and the extent of his cooperation, 
his ability to respond was conditioned by the causal 
factors of his underweight. These causal factors 
may be classified in at least five groups, and it is 
probable that any study of underweight school chil- 
dren comparable with ours as to numbers, will have 
to deal as we did with representatives from each 
group. 



A PROGRAM OF RESEARCH 205 

(1) Children showing results of faulty hygiene 
and diet due to home ignorance or lack of control. 
Probably a considerable majority in any school pop- 
ulation. 

(2) Hungry cases — candidates for relief and 
occasional cases where individual or parental idio- 
syncrasy prevents adequate food intake. 

(3) Children showing unusual fluctuations because 
of special circumstances as in the case of convales- 
cents. 

(4) Children having wasting diseases, probably in 
the incipient stage. Pre-tubercular cases were 
fairly numerous in our experience and the possi- 
bility of such maladies as syphilis, diabetes, chronic 
nephritis, malaria, intestinal parasites, must always 
be reckoned with.* 

(5) Children showing a past history of chronic 
nutritional disorders or of diseases commonly re- 
sulting in impaired nutrition. The so-called "chil- 
dren's diseases" are responsible for many such 
disorders. Premature birth, malnutrition of the 
mother during pregnancy, difficult feeding in the first 
year of life, severe repeated gastro-intestinal at- 
tacks, may all result in chronic impairment of the 
nutritional processes. Change or deficiency in some 
of the internal secretions may be cited in connection 
with this type of causal factors. It will be evident 
that a number of the children treated in our open- 
air classes belong to this group. 

Throughout our experience the ability to respond 
has been pretty consistently demonstrated to be 

* See Smith, Charles Hendee, Methods Used in a Class for Under- 
nourished Children, Am. Jour, of Diseases of Children, June, 1918. 



206 HEALTH EDUCATION 

greater on the part of children in the first three 
groups than among those of groups 4 and 5. At 
the same time the majority of the high percentile 
cases have been found among the latter groups and 
the records of our lower percentile cases show for 
the most part better average gains in proportion to 
better nutritional status. ( See pp. 134 and 151, discus- 
sion of relative gains and varying degrees of under- 
weight.) Thus the facts of oar experience do not at 
first glance support the assumption held by many 
social workers, especially those connected with 
orphanages and temporary homes for neglected chil- 
dren, that the high percentile cases respond more 
readily, and that results of treatment are less evi- 
dent as children approximate normal weight. If allow- 
ance is made, however, for the probable difference 
in the response afforded by high percentile cases 
from group 2 (hungry cases), and by high per- 
centiles from groups 4 and 5, this apparent discrep- 
ancy is easily reconciled. Statistical data from re- 
lief agencies whose cases are largely drawn from 
group 2 would doubtless only serve to confirm our 
experience that causal factors rather than degree of 
underweight determine the individual ability to 
respond. 

Major defects may be contributing factors and as 
such influence response. The effect of tonsil and 
adenoid obstructions on individual ability to respond 
has been amply demonstrated. Our experience can 
be said to offer nothing new in respect to these 
defects except as it argues success for securing such 
treatment through the agency of the school. 

The interrelation of dental caries and malnutri- 



A PROGRAM OF RESEARCH 207 

tion needs to be more definitely determined. The 
theory that malnutrition is a cause and an im- 
portant cause of dental caries, though highly prob- 
able and widely accepted has never been conclusively 
proved. On the other hand, the lack of obvious re- 
sults in weight increase attending correction of the 
defect, apparently disproves the theory that dental 
caries is a chief causal factor of malnutrition. For 
these reasons health workers have often minimized 
the importance of dental caries, but in the absence 
of conclusive proof to the contrary, its possibilities 
as a contributing factor to the condition of malnu- 
trition cannot be ignored. We must assume that in 
addition to diminishing chewing surface, its presence 
may lower general vitality and powers of resistance, 
either through the introduction of toxins into the 
system or by presenting possible sources of bacterial 
infection. 

Previous duration of the condition of malnourish- 
ment may be to some extent an index of the response 
to be expected. Where the physical examination 
reveals signs of rickets or other of the nutritional 
diseases of infancy, we may be justified in expecting 
relatively better response from the first grade child 
than from the sixth grade child, for example. The 
response shown by our first grade children may be 
partly explained by this assumption * and the grow- 
ing emphasis placed by physicians on corrective 
work for children of pre-school age becomes of addi- 
tional importance if it be true. 

* That long continued or extreme conditions of malnourishment may 
result in actual organic changes has been shown by the recent in- 
vestigations of von Pirquet in Vienna. A remarkable elongation of 
the intestine was found in children subjected to famine conditions. 



208 HEALTH EDUCATION 

Moreover, undiagnosed conditions of disease and 
physiological facts as yet hut little understood must 
be anticipated as possible causal factors. The group 
of chronic underweights reported in our open-air 
class of 1919-20 for whom no diagnosis was obtained, 
and who failed to respond in any degree to treat- 
ment, are representative of these problem cases 
whose causal factors need to be determined by fur- 
ther medical research. 

That undiagnosed incipient tuberculosis may con- 
stitute a causal factor in a large percentage of mal- 
nutrition cases is a theory advanced by some phy- 
sicians. The routine use of von Pirquet Tests on 
large groups of underweight children should furnish 
data to confirm or refute this hypothesis, as com- 
parison with the percentage results previously ob- 
tained by the same tests on average school children, 
would establish the relative frequency of positive 
reactions among the underweight group. 

At the same time, it is to be hoped that further 
research may be successful in determining the rela- 
tion of diet as a predisposing factor to tuberculosis. 
The experience of the war has amply proved that 
insufficient diet is followed by corresponding in- 
crease in tuberculosis, but has thrown no light on 
the relative part played by lowered caloric intake, 
and the deprivation of special food factors as fats, 
vitamines, and mineral constituents, as lime or phos- 
phorus. Careful laboratory experiment along this 
line of inquiry should yield important results for the 
preventive program. 

Latent syphilis has been reported as a causal fac- 
tor in a considerable percentage of cases treated at 



A PROGRAM OF RESEARCH 209 

one clinic, and further research may establish that 
this is a causal factor in a much larger number of 
cases than is now generally recognized. 

It is probable that better knowledge of the part 
played in metabolism by the ductless glands would 
throw light on many problems of malnutrition. For 
example, the question may be raised whether an in- 
creased thyroid activity was not involved in the case 
of the underweight children from the Terman classes 
(pp. 29 and 54). 

The part played by emotional disturbances and 
their effect on digestion has been pretty thoroughly 
demonstrated by laboratory research,* and the tes- 
timony of nutrition workers corroborates its im- 
portance in cases where unwise discipline, family 
friction or worry are characteristic of the home 
environment.! The fluctuations shown by the 
growth chart of the fifth grade (p. 86) indicate 
probable effects of worry or excitement during ex- 
amination week and parade week. 

The scientific interest attaching to these little 
known factors and the variety of the morbid condi- 
tions affecting nutrition must not mislead us, how- 
ever, in regard to the large percentage of " straight" 
nutritional cases whose response is dependent on 
the facts of their daily regime. For obvious reasons 
we may expect the relative percentage of such chil- 
dren to be greater in the school nutrition class than 
in the hospital clinic. The facts of the physical ex- 
amination and the investigation of individual his- 

* Cannon, W. B., Op. cit. 

t Mitchell, David, Malnutrition and Health Education, Pedagogical 
Seminary, March, 1920, pp. 65-66. 



210 HEALTH EDUCATION 

tory should serve to identify the majority of children 
with one of the five groups enumerated, at the out- 
set of any nutritional program, and provide sugges- 
tions as to individual modifications with respect to 
physical care and regime. Stool and urine examina- 
tions should be included wherever possible as an aid 
to diagnosis. 

Further stool examinations on large numbers of 
undernourished children should be undertaken to de- 
termine the frequency of special types of indigestion 
and for further investigation of parasites. Such 
a piece of research would undoubtedly afford sug- 
gestions as to corrective and preventive procedure 
with children from Group (1) as well as from 
Groups (4) and (5). Further urine examinations 
for large groups of underweight children should 
prove helpful in disclosing latent disease in relation 
to malnutrition. 

Psychological Implications 

It is often stated that a causal relationship exists 
between mental defectiveness and malnutrition. 
Bryant * says ' ' the relation of malnutrition to men- 
tal defectiveness has long been given substantial 
recognition both here and abroad in the provision 
of lunches in special schools for subnormal chil- 
dren. ' ' The most frequently used method of deter- 
mining this relationship in the investigations cited 
by her has been the calculation of the percentage of 
mental defectives that show malnutrition. In some 
cases the criterion of mental defectiveness was fail- 
ure to be promoted, and no other factors such as 

* Bryant, L. S. School Feeding, J. B. Lippincott Co., 1913, p. 225. 



A PROGRAM OF RESEARCH 211 

specific physical disabilities or attendance were con- 
sidered as causal in the retardation. If one were 
looking for the percentage of malnntrition in very- 
bright children, and should take from psychological 
data obtained in the investigation of large groups 
of school children the scores *of those %% or more 
underweight, we might have a very different story. 
The "pale brow of the scholar" would doubtless 
get some statistical justification. 

In the Terman * class, a group of high intelligence 
quotients, there was a smaller per cent of children 
7% or more overweight and a larger per cent of 
children 7% or more underweight than in any of 
the other classes studied during that year (1918). 

Discussing the possibility of mental defect being 
caused by defective bodily nutrition and the depend- 
ence of the physical health and development of the 
growing child upon the quantity and quality of his 
food, the presence of an adequate amount of sleep, 
fresh air, light, warmth, etc., Tredgold f states that 
"on the whole it may be said that these factors in 
the absence of hereditary predisposition have com- 
paratively little causal influence . . . rickets is 
sometimes the accompaniment of mental deficiency 
but I doubt whether it is ever its cause." 

Blanton % made a study of the mental and nervous 
conditions of school children between the ages of 5y 2 
and 14 years, 40-50% of whom were supposed to 
have suffered from malnutrition for a period of two 

* See p. 60. 

t Tredgold, A. F., Mental Deficiency, Wm. Wood, 3rd Ed., pp. 63-64. 

t Blanton, Smiley. Mental and Nervous Changes in the Children 
of the YolJcs-schulen of Trier, Germany, Caused by Malnutrition. 
Mental Hygiene, July, 1919. 



212 HEALTH EDUCATION 

or three years. He made no careful mental measure- 
ments but depended primarily upon clinical ex- 
aminations, observations in the schoolroom and per- 
sonal histories given by families and teachers 
through an interpreter. He concludes that "Chil- 
dren free from organic nervous disease and with 
parents of average intelligence very rarely become 
feeble-minded through malnutrition even of an ex- 
treme degree." One of the most important things 
shown in this whole study is how the nervous sys- 
tems of children of good nervous stock can resist 
malnutrition of an extreme degree extending over 
three years. 

We believe that the more direct method of attack 
is the better. We should like to see the problem 
followed up by careful measurements as to intel- 
ligence levels, reaction times, attention, and memory 
spans, motor control and the learning process upon 
children who are chronically underweight to the ex- 
tent of 15% or more, with a control group of children 
whose height-weight indices are normal or above 
normal. This should be done for varying ages. Do 
we know that 15% underweight at 7 means the same 
thing as 15% underweight at 11 or at 17? With the 
present trend toward exact physical and mental 
measurements of all children, not neglecting the 
normal child who has seemed primarily a statistical 
will-o '-the-wisp, we can best develop criteria of mal- 
nutrition. Aside from extreme cases of malnutri- 
tion, of prolonged hunger or starvation which like 
other pathological states would cause disintegration, 
we cannot say that malnutrition irrespective of other 
factors produces or runs hand in hand with mental 



A PROGRAM OF RESEARCH 213 

defectiveness. In many types of mental processes 
the reactions of the undernourished child are equal 
or superior to the average of his age group. The 
traits in which he may prove less capable seem to be 
resistance to fatigue under response to uninter- 
rupted or complex stimuli, and exaggerated emo- 
tional responses under normal stimulation. A prob- 
lem worthy of study both for the undernourished 
and for the hearty child is fatigue with special ref- 
erence to the period of recovery. 



F 




» M u • 



» e b 9 



5* 
5* 
53 
52 

** 

50 
49 
48 
47 
46 
45 
44 
43 
42 
41 




Chart of low percentile case showing excellent response. Boy 
6 yrs. of age, Austrian father, Russian mother. Underweight 
8% Sept. 1 91 9; 2% May 1920; normal weight Sept. 1920. 
Physical history shows measles (8 mos.), anti-toxin given for 
suspected diphtheria, bad tonsil condition. Mental history 
shows high intelligence, I. Q. 126 (Terman). Social history 
shows father short, medium build, mother medium height, 
plump. Family of 8; flat of 5 outside rooms, 6 windows. 
Comfortable well-kept home, mother a "good cook," Note: a 
case of special interest where the child's determination to follow 
an imposed regime resulted in later enlistment of the mother's 
cooperation. Tonsillectomy recommended Oct. 1919; per- 
formed Dec. 1920. 

214 



|tV..Cn*JL/» 

*..,,,....42 
»*. 34 



H 



Under w eight i 

Pw Cent Und«rw*t|!H., 



41 

.....7 
17 



45 
44 

4a 

42 
41 
40 

39 
38 
37 
36 
35 
34 
33 
32 
31 



°w 




Chart of high percentile case showing unsatisfactory response. 
Boy 6 yrs. of age, Austrian parentage. Underweight, 17%. 
Sept. 1919; 12% May 1920; 16% Sept. 1920. Physical history 
shows measles (2 yrs.) chicken pox (3 yrs.) "convulsions" (2-4 
yrs.), chronic digestive disturbances apparently due to unwise 
home regime, especially as to habits of eating. Mental history 
shows I. Q. 91 (Terman). Social history shows father thin 
delicate type, mother 5 ft., 7% underweight; family of 6; flat 
of 4 small rooms, ground floor, poor ventilation. Entire family 
suffering from digestive troubles : Note : lack of home coopera- 
tion and duration of unsatisfactory conditions seem responsible 
for failure to improve. 

215 



.i^k, 4© 



K 



PoOrat UU4— l» 9 



1! 



51 

50 
49 

48 
47 
46 
45 
44 
43 
42 
41 
40 
39 
38 
37 




..../jr~ 




Chart of high percentile case showing unusual response. Boy 
6 yrs. of age. Father Russian Pole; mother, Austrian. Under- 
weight, 20% Sept. 1919; 9% May 1920; 9% Sept. 1920. 
Physical history shows small size at birth (4^ lbs.), measles 
( 1 Yz yrs. ) , whooping cough ( 5 yrs. ) , German measles ( 5 yrs. ) . 
Mental history shows I. Q. 108 (Terman), evidences of emo- 
tional instability. Social history shows parents divorced, mother 
and child living with grandparents, mother 5 ft. 2 in. tall, 13% 
overweight, only child, family of 9 adults, flat of 5 rooms, 
fairly large, all outside windows; comfortable economic circum- 
stances. Note: Cooperation of mother and child successfully 
enlisted. 

216 






K 



A^-D r™i.*i\ 



55 
54 
53 
52 
51 
50 
49 
48 
47 
46 

45 
44 
43 
42 
41 




Chart of low percentile case showing excellent response. Boy 
of 6 yrs. of age. Russian parentage. Underweight 8% Sept. 
1919; 2% above normal May 1920; 2% below normal Sept. 
1920. Physical history shows whooping cough (8 mos.), 
measles (1 yr.), pneumonia (2 yrs.), tonsillectomy (5 yrs.). 
Mental history shows I. Q. 104 (Terman). Social history 
shows father short, 5% overweight; mother short 13% over- 
weight ; family of 6 ; flat of 4 rooms, light, well-ventilated, well- 
kept. Note: Cooperation of parents willing but rather unin- 
telligent. 

217 



R 



AgeO CndJLfw* 



Weight . . 



^iH-IHfcO 



Normal V/t^^w, 
Csr Cent. Underweight J 



43 



• t f ft «i*cirauM(4uatoiQi0»ttu m a as u s » 



49 

48 

4? 

46 

45 

44 

43 

42 

41 

40 

39 

38 

37 

36 

35 




Chart of case 12% underweight showing excellent response. 
Boy of 6 yrs. of age, Russian parentage. Underweight 12% 
Sept. 1919; normal weight May 1st, 1920; 4% underweight 
Sept. 1920. Physical history shows diphtheria (3 yrs.) ; measles 
(4 yrs.) ; chicken pox (4 yrs.) ; frequent sore throats due to 
enlarged tonsils, cardiac symptoms, imperative need of dental 
care. Mental history shows I. Q. 92 (Terman). Social history 
shows father short (5 ft.), slight (circ. 6% underweight); 
mother, medium height, normal weight. Family of 7 ; flat of 4 
rooms; all windows on a court. A comparatively comfortable, 
well-kept home. Note: Cooperation of parents resulted in cor- 
rection of dental defects and tonsillectomy. 

218 



4 



4? 
' 46 
45 
44 
43 
42 
41 
40 
39 
38 
3? 
36 
35 
34 
33 




Chart of high precentile case showing unsatisfactory response. 
Boy 6 yrs. of age, Russian parentage. Underweight, 1 6% Sept. 
1912; 11% May 1920; 8% Sept. 1920. Physical history shows 
small size at birth (4 lbs.) pneumonia in infancy, adenoid opera- 
tion (3 yrs.) ; bronchitis frequently, cardiac symptoms present. 
Mental history shows I. Q. 108 (Terman). Evidences of nerv- 
ous instability and development of chorea. Social history shows 
father short (5 ft.), 10% overweight; mother, medium height, 
overweight. Family of three ; flat of 3 rooms, 1 northern ex- 
posure, 2 on court. Home fairly comfortable and well-kept. 
Note: Primarily a medical case. Cooperation of mother un-/ 
usually good. Hospital care for chorea began July 1 920. Child 
kept constantly in bed, did not return to school 1920-21. 

219 



N 



T 






47 
46 
45 
44 
43 
42 
41 
40 
39 
38 
37 
36 
35 
34 
33 




Chart showing failure to respond. Boy 6 yrs. of age. Russian 
parentage. Underweight, io% Sept. 1919; 9% May 1920; 
11% Sept. 1920. Physical history shows small size at birth 
(3^2 lbs.) ; he was the smaller of twin brothers; 14 months 
teething; chicken-pox (ij^ yrs.), measles (2^4 yrs.), Mental 
history shows evidences of retarded development and infantile 
attitudes. I. Q. 77 (Terman) ; has failed of promotion during 
two years of schooling. Social history shows father short (5 ft.), 
normal weight for height; mother 5 ft., 21% overweight for 
height ; family of 7 ; 3 adults, crowded home, 3 small rooms 
opening on court. Note : cooperation of mother willing. 

220 



CHAPTER IX 

INTERPRETATIONS AND RECOMMENDATIONS 
FOR AN EDUCATIONAL PROGRAM 

When we review the experiment at P. S. 64 in its 
entirety and contrast the program offered by the 
nutrition class with the traditional school attack 
on health problems, the emphasis placed on de- 
monstrable results for well-being must be recognized 
as the outstanding contribution the experience has 
afforded toward the conception of a general educa- 
tional procedure. That health education must be 
rendered susceptible of evaluation is the challenge 
of the nutrition class to the school. All the diffi- 
culties encountered in our attempt to secure appre- 
ciable results and to evaluate them correctly do not 
lessen this emphasis on their importance for the 
positive health program. 

Principles Determining Results 

It will be evident therefore that whatever addi- 
tional suggestions the experience may offer toward 
the shaping of a school health program must be 
determined in accordance with this first and fund- 
amental consideration of returns secured. If we sub- 
ject our record to the test of appreciable results, 
what principles emerge as governing the success of 
an educational procedure for health making? Ap- 
parently we must concede the importance of the 
following : 

221 



222 HEALTH EDUCATION 

Gains have been largely dependent on initial 
physical status and proportionate to the rela- 
tively superior or inferior condition of the in- 
dividuals considered. 

Gains have been largely influenced by the 
technique employed for enlisting cooperation 
from the children. 

Other conditions being equal, gains have been 
in direct proportion to the influence exerted on 
the home and the resulting parental cooperation. 

Gains appear to have been appreciably in- 
creased when favorable conditions directly af- 
fecting the nutritional processes have been in- 
troduced within the school environment. 

The first of these tentative findings is of special 
significance for its bearing on the possible value of 
our procedure as a preventive program by which 
the well-being of the normal child may be increased. 
Certainly the results shown in those groups most 
carefully observed by us suggest that so-called 
normal children, and children approximating cur- 
rently accepted norms may benefit by the procedure 
in proportion to their superior physical condition. 
The comparative gains made by Sections I and II 
of the fifth grade boys may be cited in this connec- 
tion. It has been shown (p. 154) that the 22 children 
of this class who "graduated" in the fall of 1918 
(Section II) averaged in two years a gain of 3.6 
pounds more than the Wood norms and of 4.1 pounds 
more than the Porter norms for boys of their age 
and height. This is an average of 2.61 pounds more 



AN EDUCATIONAL PROGRAM 223 

than that gained by the remaining members of the 
group (Section I) who were children averaging a 
greater degree of underweight and who gained in the 
same period an average of .99 pound more than the 
Wood norms and 1.49 pounds more than the Porter 
norms. Similarly, Section I of the first grade chil- 
dren (1919-20 program) those 8-9% underweight 
gained an average of nearly 5 pounds more from 
October to October than the children of the sections 
respectively 10-12% and 13-20% underweight. 

The record of gains shown by the fifth grade boys 
at the end of two years, .fourteen months after the 
period of their instruction had been discontinued, 
is one of the most striking facts of the entire ex- 
perience.* It is unfortunate that corresponding fol- 

* As the great majority of the children considered were of Jewish- 
Eussian or of Jewish-Austrian parentage the question of racial or 
stock variation in relation to physiological age may be raised in 
connection with these figures for gains between 11 and 13 years of 
age. There are, however, no existing norms from which we may 
determine how far earlier pubescence and attendant variations in 
height and weight must be considered. The weights of 68G Jewish 
boys 14 years of age who were granted working papers in New 
York City between July, 1914, and April, 1915, were found to average 
2 pounds above those of 14 year old boys of other racial antece- 
dents (Frankel and Dublin, Heights and Weights of New York City 
Children, Metropolitan Life Insurance Co., 1916). This average was 
obtained, however, without discrimination as to national antecedents, 
whether Jewish-German, Jewish-Russian, Jewish-Polish, or other, and 
beyond raising the question of racial variation and physiological age 
throws no light on standards for Jewish-Russian and Jewish- Austrian 
boys between the ages of 11 and 13. 

Twenty-five boys of our Control Group, organized in September, 1918, 
were observed through 18 months, to June, 1920, during which period 
their average weight closely approximated the Burke-Boas norms for 
the given heights from 11 to 12% years. The gain averaged by the 
Control Group for this period was 12.11 pounds, that of Section I, 
12.25 pounds or .13 pound more than the control and that of Section 
II 15.37 pounds or 3.26 pounds more than the control. Thus at 
12% years the average gains of Section II in excess of the control 
group do not differ materially from the gains shown by them six 
months later (3.6 pounds) in excess of the Wood norms. From the 
data available it would appear that the superior weight increase of 
this group was presumably due to a better regime. 



224 HEALTH EDUCATION 

low-up records were not attempted for all our groups 
especially for the children of the open-air and Ter- 
man classes, for the possibilities they might have 
afforded for further suggestions as to comparative 
long term results. It will be evident, however, that 
a procedure affording gains for children who ap- 
proximate normal development, and resulting in con- 
tinued gains subsequent to the period of instruction, 
is calculated to meet the fundamental requirements 
of the educational ideal, a health program that shall 
combine preventive possibilities with those more im- 
mediate and corrective in character. 

The technique for enlisting group interest and ac- 
tion must be the first consideration in the conduct 
of the health procedure. Save for the attempted 
school feeding program of the first term and the pro- 
visions made for our open-air classes, it will be 
obvious that the actual school programs arranged 
for our'several groups were negligible so far as they 
afforded opportunity for actual food-taking, rest, 
sleep, fresh air, and the other details of the health 
regime. Thus any results from our procedure were 
chiefly secured by its provision of a sufficient stimu- 
lus to ensure the child's cooperation in carrying out 
the prescribed regime at home and elsewhere in the 
outside environment. That this is the real function 
of the class instruction in the nutrition program is 
a point too little understood. Indeed the subject 
matter content is too often accepted as its more 
obvious raison d 'etre, and the relative value of class 
and individual instruction is sometimes debated by 
physicians and nutrition workers, who fail to ap- 
preciate that the appeal to group and social interests 



AN EDUCATIONAL PROGRAM 225 

afforded by the class sessions is what determines 
their importance rather than their informational 
character. 

The appeal of the class session rests on two im- 
portant characteristics of the child's psychology, the 
desire to conform to group standards and the desire 
for full participation in the activities of the group. 
The health procedure can and should utilize these 
native desires for its own purposes. Evidently the 
disciplinary difficulties met with in our initial pro- 
gram were largely due to disregard of them, espe- 
cially to failure to appreciate the child's proper 
aversion to being singled out as different from his 
fellows. So far as our later programs have been 
successful in identifying the health procedure with 
recognized group standards and with the customary 
group activities of the class-room, our position has 
been correspondingly strengthened. We can appre- 
ciate, however, that a health program recognized by 
the entire school would have, by virtue of that fact, 
greater significance for the enlistment of the child's 
cooperation than a program limited to any class or 
several classes within the school. That the socializa- 
tion of the class procedure, and the resulting more 
active participation permitted the individual, has 
played its part in securing interest and increasing 
cooperation in our two later programs, will also be 
evident. 

Evaluation of success and failure for the child 
must be measured by his cooperation and by in- 
dividual gain in fitness rather than by his compara- 
tive gain in relation to that of his fellows. Atten- 
tion has already been called to the fact that the 



226 HEALTH EDUCATION 

original idea of stimulating competition between the 
members of a class was modified, and later entirely 
discarded by us, with no loss to the effectiveness of 
our procedure. So many factors enter into the prob- 
lem of health that failure to gain or to keep up to 
standard may result from many causes over which 
a child has no control. On the other hand, he may 
show gains by reason of individual endowment while 
refusing cooperation. To emphasize failure after he 
has cooperated to the best of his ability, to reward 
him for gaining when he has not really cooperated 
are mistakes as unfortunate from the educational as 
from the moral standpoint, for they are fatal to the 
continuance of interest and effort. They are, how- 
ever, the unavoidable accompaniments of the appeal 
to competition. The situation here is not different 
from that attending other school activities. Unequal 
physical endowment is on a par with unequal mental 
endowment. One of the chief dangers of the appeal 
to competition is its possible effect on the children 
of less fortunate endowment. Among individuals of 
certain nervous organization we may even establish 
a sense of inferiority with its train of consequences, 
from apparent indifference and apathy to open re- 
bellion and misdemeanor. The seriously retarded 
children whose presence in the regular school grades 
is so universally disturbing to discipline, sufficiently 
illustrate the seriousness of this problem. Our 
health procedure must not be allowed to increase the 
number of irreconcilables within the school. It must 
ensure to the individual the satisfactions and re- 
wards of his endeavor. 

Again, the child must be held responsible only for 



AN EDUCATIONAL PROGRAM 227 

his cooperation in such activities as his environment 
affords. The program of instruction that demands 
from him cooperation he is unable to give, or fixes 
responsibility on him for environmental conditions 
he is unable to control will not succeed, however in- 
forming or stimulating to action it may be. Our 
health program therefore must go beyond the limits 
of the school environment and the school day. It 
must make a consistent attempt to secure home con- 
ditions that permit the stimulus of the class pro- 
cedure to function in the activities of the prescribed 
regime. Thus the success of the school program of 
health education is dependent on a serious program 
of education in the community. The facts of our 
experience amply testify to the dependence of suc- 
cess on the cooperation of the home, and it may be 
well to consider the relative position of the school 
as an agency for securing cooperation of this kind. 
Where a corrective procedure is undertaken the 
school is doubtless at a disadvantage when con- 
trasted with the hospital clinic, not only because its 
opinion in matters of health does not command the 
same deference, but from the additional circum- 
stance that the parents asking assistance from the 
hospital are seeking that assistance primarily be- 
cause they are aware of the child's need. They are 
from the outset prepared to accept advice; and the 
same is true of the parents who, by seeking the 
assistance of welfare agencies, acknowledge their 
own inability to supply the necessary conditions for 
the family's well-being. When the school enters the 
field, however, it must assume the initiative ; it must 
be the first to apprise many parents of the fact that 



228 HEALTH EDUCATION 

all is not well. The first intimation that the child is 
not entirely sonnd may be the visit of the nutrition 
worker and the request for the stripped examination 
by a physician at the school. Malnutrition to the 
parents in the neighborhood of P. S. 64 is merely the 
state of being "skinny" and if any relative, near or 
remote, has been lank or simply unusually tall, this 
fact has probably been a sufficient answer to any 
suspicion that a child's small appetite or flabby 
muscles might indicate ill health. Under such cir- 
cumstances we must expect that the necessary home 
cooperation will be difficult to secure. Indeed, our 
experience seems to show that it cannot be secured 
without a campaign of patient and consistent effort. 
Nor is this all, for where progress is slow and dis- 
couraging the hospital and social welfare agency 
may lose the patient. Cases that do not respond, 
parents that refuse cooperation, inevitably drop 
from their rolls, but such is not true of the public 
school. The chronic case, the unadjusted child, the 
child from the ill-regulated home, will still remain 
members of the school population ; and their records 
will inevitably contribute to lowering the sum total 
of results obtained. 

Our experience has been limited to the demands 
of a corrective procedure but it will be evident that 
an extension of the health program to include 
normal children and a preventive procedure, must be 
accompanied by a corresponding extension of the 
community program. Difficult as the school may 
find it to enlist the cooperation of parents whose 
children are normal, whose economic circumstances 
are independent and assured, it is the one community 



AN EDUCATIONAL PROGRAM 229 

agency that can attempt to do so. In a program of 
health education, more clearly perhaps than in any 
other, the futility of thinking and acting by different 
standards becomes apparent. In so far as home 
standards and practices remain at variance with the 
standards for health habits presented by the school 
to the children, appreciable results are not to be ex- 
pected. While it is true that individual children in 
our experience succeeded in enlisting for themselves 
the necessary cooperation from their parents, and 
modifying their home environment to some extent 
in accordance with the ideals of our health teaching, 
such cases were few and chiefly confined to the 
children of superior intelligence. Unquestionably 
we may expect that a degree of influence will be 
exerted on the home where the interest of the chil- 
dren has been enlisted. That it will, unaided, suffice 
to achieve definite results in the great majority of 
cases appears improbable, and from the larger edu- 
cational viewpoint undesirable as well. Intelligent 
adult control of the environment is the goal to be 
achieved, not dictation to the adult by the child. The 
function of the school must be to inform and enlist 
the adults of the home, and at the same time to re- 
inforce intelligent control within the home, through 
use of its unequalled opportunities for enlisting the 
child's cooperation. 

The efficiency of the health program will be ap- 
preciably increased in proportion to the advan- 
tageous factors, that is the activities and conditions 
favorably affecting the nutritional processes, pro- 
vided by the school environment. It is to be regret- 
ted that our series of experiments cannot furnish 



230 HEALTH EDUCATION 

more varied and convincing examples of such activi- 
ties and conditions and of their influence on results. 
The conditions attending the mid-day dinner of the 
first experiment prevented our realizing appreciable 
gains from that source. There is some probability, 
however, that the mid-morning lunches served dur- 
ing the same term appreciably increased the gains 
and are responsible for the relatively good showing 
made by our first classes at the least favorable sea- 
son of the year as compared with that of the fifth 
grade children during the same season a year later. 

The contrast between the results achieved by the 
open-air classes during the fall months of 1918 and 
those shown by the fifth grade for the same period 
is the best example our records afford as to the in- 
fluence of factors favorably affecting nutritional 
processes. Optimum conditions of ventilation, sun- 
shine, facilities for rest and food-taking, general re- 
laxation of the usual school tension, these factors 
in combination appear very materially to have in- 
creased the gains made prior to the onset of extreme 
cold weather and the season of minimal increase. 
(See Chart A, p. 84). 

But the value of advantageous factors for the 
health program is not entirely in their physical ef- 
fect. Their greater educational significance must be 
considered as well. From this standpoint they are 
much more than merely corrective or palliative 
measures and we may well claim for them a legiti- 
mate place in every school environment. The actual 
weight-getting results to be anticipated from the 
mid-morning cup of milk or cocoa for example, are 
relatively negligible as compared with the results to 



AN EDUCATIONAL PROGRAM 231 

be anticipated from cultivating a taste for them, 
especially where there is, in addition, an understand- 
ing of their desirability as beverages to replace tea 
and coffee in the home dietary. 

Criteria for Educational Experiences in the Health 

Program 

If we analyze the activities provided in the pro- 
gram of the nutrition class we will appreciate they 
are of two types, those affording the child experi- 
ences at first hand, and those affording informational 
experiences, and that the "advantageous factors" 
without exception provide first hand experiences. 
Educational tradition however is so largely bound to 
informational experience, that it is only with diffi- 
culty the school can be brought to think in other 
terms and to incorporate activities that will supply 
the necessary advantageous factors in its practice. 
The weakness of the school's traditional attack on 
health, as embodied in the text book of hygiene, the 
home economics course, the civics syllabus, the 
biology syllabus, or in such socialized group activi- 
ties as class discussion, story-telling and dramatiza- 
tion is inherent in the fact that the health experi- 
ences provided by these activities are informational, 
and the habits acquired through them are of little 
or no value as directly affecting physical condition. 
This distinction will be the more evident if we con- 
trast the procedure employed in another field where 
health is also the objective and where experience at 
first hand is frankly accepted as the sine qua non of 
an educational program. 

Difficult as the school may find it to think in terms 



232 HEALTH EDUCATION 

of first hand experience, the department of physical 
training mnst of necessity ignore any other kind, 
and for this reason its procedure affords some com- 
parisons of value. 

While a considerable body of subject matter, his- 
torical, social and physiological, might conceivably 
be developed in connection with the gymnasium and 
playground and such activities as, for example, ten- 
nis or baseball, no attempt is made to use such 
material in the teaching program, nor are the 
hygienic benefits to be derived from participation 
discussed in class more than incidentally. The great 
consideration is that the children actually partici- 
pate, use the exercises, play the games, enjoy them, 
become habituated to the demands they make on the 
bodily machinery and the sensations attending them, 
and come finally to desire these for their own sake. 
This is a true habit-forming program. The advan- 
tageous factors recognized by the nutrition class 
procedure afford corresponding opportunities for 
the acquisition of habits affecting health, and this 
is the objective that must be kept before us. Al- 
though the subject matter afforded is infinitely 
rich and important to society such claims must not 
confuse us as to the secondary place to be accorded 
it in the efficient health program. 

The special limitations of subject matter in health 
education must be recognized before a just estimate 
can be placed on the value of dramatic activities and 
their place in a health program. Obviously they 
provide both first hand and second hand types of 
experience. It will be easily recognized however 
that although a certain amount of bodily activity 



AN EDUCATIONAL PROGRAM 233 

and emotional satisfaction is usually incidental to 
them, such first hand experiences as they offer fail 
to supply the more important advantageous factors. 
Thus, however desirable the opportunities they may 
afford for first hand experiences in social education, 
manual activities, and constructive thinking, their 
value for the health program is as a stimulus to the 
child's cooperation, and lies in the appeal they make 
to group interest by affording participatory ex- 
periences in relation to informational material. 

The use made of dramatization in our series of 
experiments was limited to the class activities of the 
first grade (1919-20). It consisted in such recapitula- 
tions of subject matter, previously presented in story 
form, as the children could organize for themselves. 
Thus it followed the recognized educational ideal for 
dramatic activities at this age period. By familiariz- 
ing the little child with subject matter under con- 
ditions of special appeal to interest, that is through 
participation in group activities, it provided an ef- 
fective stimulus to cooperation. In developing a 
procedure for the older classes of our 1918-19 pro- 
gram the need for dramatic activities was not felt, 
as the socialized class discussions apparently offered 
sufficient opportunity for participatory experiences 
and the resulting stimulus to interest. Thus a dif- 
ference in age period, and the resulting difference 
between play level and work level activities, very 
materially affected our use of dramatization. 

The greatest use of subject matter was made, as 
has been described, with the boys of the fifth grade 
class, in the 1918-19 program, and without appre- 
ciable resulting gains, although the question may 



234 HEALTH EDUCATION 

legitimately be raised whether the excellent long 
term results shown by this group may not have been 
influenced by the considerable period of intensive 
instruction given them. In conceding the probability 
of this, the importance of the conditions under which 
the instruction was given must be urged. In addi- 
tion to the successful enlistment of cooperation from 
the children and their parents, the subject matter 
used was closely related to the facts of a daily 
regime of health habits. Imperfect as the provisions 
for this regime may have been, either within the 
home or the school environment, the use of the sub- 
ject matter in direct relation to the experiences af- 
forded was undoubtedly vital to its effective func- 
tioning. To reinforce and interpret first-hand ex- 
periences is the true place of subject matter in a pro- 
gram where health habits are the objectives. It is 
through such a use of subject matter that the child's 
cooperation becomes informed and purposeful, and 
his attitude toward health a creative one. It is the 
weakness of the home that it too often insists on un- 
informed cooperation, and the strength of the school 
that it is possessed of resources capable of investing 
the facts of hygiene with all the dignity and im- 
portance of their place in the world of science. In- 
deed, as an approach to the study of science, the 
subject matter involved is unsurpassed, and as such 
its development and use by the school is greatly to 
be desired. As a factor in the health program, how- 
ever, it is easy to over-rate the place it should occupy 
and to devote to it time and resources that can be 
more effectively employed, if our criterion is to be 
that of appreciable results in physical well-being. 



AN EDUCATIONAL PROGRAM 235 

Implications for School Procedure 

If the foregoing interpretations may be accepted 
as offering a true analysis of the factors determin- 
ing gains in our series of experiments, their implica- 
tions for practical procedure in the school may be 
grouped under the following recommendations : 

The essential features of the nutrition class 
procedure should be incorporated in general 
school practice, and the resulting health pro- 
gram extended to all children, irrespective of 
initial physical status. 

Closer relationship between the home and the 
school in matters affecting health habits should 
be accomplished, through definite provision for 
community enlightenment, and the enlistment of 
parental cooperation. 

The school should adjust its equipment and 
procedure to afford the greatest possible num- 
ber of "advantageous factors," and undertake 
to interpret these in their relation to a compre- 
hensive program of personal hygiene. It should 
supply conditions that permit the development 
of health habits because of the environment 
rather than in spite of it, as is so largely the case 
to-day. 

The general and preventive program of 
health education should be supplemented by 
special provision for children departing from 
the range of normal variation in respect to 
growth, as well as for those showing indications 
of disease, infections, or the usually recognized 
physical defects. 

SCOPE OF THE PREVENTIVE PROGRAM 

That the essential features of the nutrition pro- 
gram may be profitably extended to normal children 



236 HEALTH EDUCATION 

with a view to further increasing their growth and 
vigor, appears to be indicated by our data on the 
comparative weight increase of children of varying 
degrees «of fitness, under an improved regime sup- 
plemented by instruction. There is nothing to show 
that children of standard or superior fitness may not 
be capable of corresponding improvement under 
similar conditions. Moreover we hardly need to 
emphasize the fact that important as growth may be 
in providing an index of condition, increased physi- 
cal vigor must yield additional results of greater or 
at least equal importance. Thus whatever the limi- 
tations racial and family status may impose on in- 
dividual development in height and weight, the pos- 
sibilities for increasing energy, muscular develop- 
ment and endurance are not correspondingly limited. 
Health education based on the needs of normal chil- 
dren must consider such results, and be prepared 
to evaluate them in addition to those in growth. 

It will be evident that our nutrition classes gave 
only passing consideration to results of this kind 
and that, through them, influence was continually 
exerted to prevent over-exertion and emphasize the 
need of rest, rather than to encourage bodily activity 
or make provision for muscular development. These 
limitations were imposed by the conditions at- 
tending a corrective program for underweight 
children. Had our work concerned itself with 
normal children the contribution of the playground 
and gymnasium must have been included, as they 
provide the most important " advantageous factors" 
available in the school environment. The preventive 
health program must definitely relate the work of 



AN EDUCATIONAL PROGRAM 237 

the school department of physical training to a 
broader plan of physical education. 

Continuity. — The scope of the health program 
in regard to continuity is of primary importance 
if results of lasting value are to be secured. 
At the outset our program had for its object 
the ' ' graduation " of the children enrolled, as 
soon as they should attain normal weight for 
height and age. Administrative considerations, 
however, led us to organize our classes with 
reference to the school year and made neces- 
sary the retention of any " graduates" for the fixed 
period of at least a term. Observation of the fluctua- 
tions shown by the individual charts under these 
conditions, leads to the conclusion that underweight 
children "making normal" cannot be regarded as 
definitely "cured," and therefore to be at once dis- 
missed from educational influences. On the contrary 
they suggest the necessity of an extended period of 
intensive educational influence, and the desirability 
of a continuous period of supervision. It is probable 
that a health program organized to provide con- 
tinuous environmental influences supplying the 
necessary "advantageous factors," with current 
evaluation of growth and physical vigor, will func- 
tion to the best advantage when combined with a 
period of intensive educational influence. 

Age periods. — This raises the question as to 
the most desirable age period for the intensive 
program. Our work was chiefly concerned with 
children in the pre-pubertal stage of develop- 
ment or at the age of school entrance. It will 
be obvious that both periods offer advantages. 



238 HEALTH EDUCATION 

With the younger children we recognize the desir- 
ability of intensive work at a period when habits, 
especially dietary habits, are still fully under paren- 
tal control, and where the possibilities of home co- 
operation are correspondingly increased. Certain 
facts of growth at this stage, especially those con- 
cerned with the formation of the permanent teeth, 
argue the special importance of intensive educa- 
tional influence during the first year or two after 
school entrance. From the standpoint of establish- 
ing a creative attitude toward health, the later age 
period probably affords better opportunities for 
educational procedure. Other considerations may be 
urged as well. The great increase of tuberculosis 
that occurs during the years of pubertal change, re- 
flects the special need of increased physical fitness 
at this age period. The school, by supplying inten- 
sive educational influence prior to this period of 
special susceptibility, could in a very special sense 
offer a preventive health program. While our study 
was of necessity limited to children below the high 
school, it will be apparent that certain aspects of 
health education can best be developed in relation 
to a later age period and that an intensive period 
of educational influence is especially desirable dur- 
ing one of the years of high school, when the social 
and civic aspects of health can be more effectively 
related to the facts of individual development and 
scientific interest. Consideration of each age period 
will serve to establish its claim to special provision 
and lead to the conclusion that our health teaching 
can be most effectively accomplished by definite pro- 



AN EDUCATIONAL PROGRAM 239 

vision in the school curriculum for at least one year 
of intensive work at each of these age periods, pro- 
viding the necessary experiences and their interpre- 
tation at successive educational levels. 

The Community Program. — Consideration of the 
program of home visiting and parents' meetings 
developed in the course of our work must lead 
to the conclusion that any suggestions it may 
afford for the larger program of health edu- 
cation must of necessity be inadequate. For it 
will be evident that our community work has been 
limited to the particular needs of the corrective pro- 
gram, in a section whose homes were for the most 
part ignorant, and little above the low water mark 
of economic independence. Thus the problems met 
were very similar to those usually encountered by 
the social service workers of the hospital clinic and 
welfare agency, and the solutions offered are un- 
mistakably in terms of relief as well as of education. 
It will be evident that the basic questions of relation- 
ship between home and school are effectually be- 
fogged by such conditions. Until successful demon- 
strations of community enlightenment shall have been 
made in school communities where education and 
economic independence are general in the homes, the 
true character and scope of this part of the health 
education program will not become apparent. We 
may anticipate, however, that qualities of leadership 
are necessary, and a democratic rather than a 
benevolent attitude. Initiative, social vision, knowl- 
edge of both school and community resources, and 
ability to organize them, these probably are de- 



240 HEALTH EDUCATION 

manded rather than the more specific techniques and 
special types of training now identified with the cor- 
rective procedure. 

A few evident facts of our experience are of 
special significance in relation to any community 
program. First among them we may mention the 
necessary time element involved, and the lack of 
anything spectacular in the results accomplished. 
These two characteristics argue the educational 
health procedure ill-adapted to purposes of propa- 
ganda, if by propaganda we mean a demonstration 
necessitating early and spectacular results. Thus 
attempts to enlist community interest through the 
organization of demonstration classes, are hardly 
calculated to achieve success. Initial propaganda 
should preferably take other forms and be followed 
by the health program or the nutrition class. On 
the other hand the whole testimony of our experience 
points to the possibilities for community enlighten- 
ment attending a consistent and long continued dem- 
onstration of the educational procedure. 

That general educational principles apply to the 
adult and community program, as well as to the pro- 
visions made for the children may also be urged, 
and thus we may expect informational experiences 
to function in proportion to their association with 
experience at first hand. For this reason the records 
offered by the weight charts and the discussion of 
them in the parents' meetings offer certain sugges- 
tions as to methods applicable to a general com- 
munity program. 

Our experience in connection with reports made 
by the children as to details of the home regime 



AN EDUCATIONAL PROGRAM 241 

emphasizes the necessity of accuracy in such reports, 
and the difficulty of securing it unless very definite 
provision for verification through home visiting and 
parental cooperation can be made. Even so there is 
much opportunity for error, many parents being as 
inaccurate as the children in regard to specific de- 
tails. Moreover the additional expense and labor 
attending such verification makes it prohibitive un- 
less undertaken as in our experiments, for special 
classes and for children needing a corrective pro- 
gram. Under the circumstances any system of re- 
wards or credits based only on reports from the 
children appears distinctly undesirable, and to be 
avoided as placing a premium on inaccuracy, and 
very possibly on hypocrisy. It would seem that 
effective relationship between community and school 
in the health program must be developed along other 
lines. 

Adjustments within the School. — Within the 
school the health program demands provision for 
continuous supervision and record-keeping for every 
child, provision for the greatest possible number of 
advantageous factors within the school environment, 
provision for enlisting the intelligent cooperation of 
all children in respect to advantageous factors both 
at home and in school. 

To effect a continuous supervision of individual 
condition in regard to health, the best available 
provisions for physical examinations and medi- 
cal inspection should be supplemented by fre- 
quent records of height and weight. In addi- 
tion to its importance as a record from which cur- 
rent results may be evaluated, the individual 



242 HEALTH EDUCATION 

growth chart is a device of undoubted educational 
value. It presents a graphic record of facts to be 
interpreted by relating the child's experiences at 
first hand directly to the necessary informational 
material. As a means of enlisting interest and hold- 
ing it, it is without doubt the best device we have, 
and the only one of its kind. Like all other devices 
in educational procedure, it is susceptible of misuse. 
The successive modifications adopted by us in regard 
to its use reflect the more serious possibilities of this 
kind.* Weight and height measurements present 
many opportunities for inaccuracy and the keeping 
of the current records must be in the hands of care- 
ful and experienced adults, if they are really to ful- 
fill their function in affording the necessary data 
for evaluating the health procedure. For this 
reason the responsibility for taking measurements 
cannot be relegated to the children themselves and 
undertaken as a class activity, excellent as such an 
experience might be from the educational standpoint. 
It is a question how far the class teacher may be 
relied on for such measurements. In our work all 
measurements and records were made by the nutri- 
tion workers who had been carefully instructed as to 
methods. Under the supervision of trained workers 
the experiences incidental to height and weight tak- 
ing may well be made to yield their quota of par- 
ticipatory activities for the children. The conditions 
obtaining in the eye clinic room a P. S. 64, how- 
ever, effectually prevented the development of the 
educational possibilities the measurements should 
have afforded, beyond informal discussion with the 

* See Appendix C. 



AN EDUCATIONAL PROGRAM 243 

child of his own gains or losses in relation to his 
daily regime. 

The provision of advantageous factors within the 
school environment should be such as to supply con- 
tinuous experiences that will be health building and 
habit-forming. How can this be accomplished? 
Obviously the school 's function in regard to facilities 
for feeding, sleeping and bathing must always be 
limited. Whatever provision it may make in these 
directions must be of value rather as they afford 
suggestions for the home or supplement its provi- 
sions. The conditions obtaining in the average 
homes of any school community must determine the 
relative need for such experiences and, to an extent, 
the method of supplying them. 

Thus the comparative failure of the mid-day 
luncheon to function in the program of P. S. 64 is 
inconclusive as to its possible advantages in a dif- 
ferent community. Properly conceived and executed, 
the school lunch could be made an ideal educational 
vehicle. Examples of a carefully planned lunch- 
room service may be found in several of our welfare 
agencies, combining a program of full feeding, with 
opportunity for the broadening of dietary habits, 
and the inculcating of healthful table habits. It is, 
however, a long step from the commercially con- 
ducted lunch-rooms of our city schools to the educa- 
tional ideal. 

The difficulties concerning the administration of 
the school lunch are, indeed, so many, that it is a 
serious question how far it can be considered a prac- 
tical undertaking if carried out in the ideal way, 
which involves not only the careful selection and 



244 HEALTH EDUCATION 

preparation of the food supplied, but also the super- 
vision of the children in their selection of food and 
eating habits. The noise and confusion generally 
found in the school lunch-room, the haste that so 
often prevails, are questionable attendants to a satis- 
factory meal. It is only too evident that our large 
public schools cannot provide a substitute for the 
home in these particulars, although much can be done 
to improve the conditions usually found, if the value 
of serenity and of desirable eating habits can be 
fully established in the minds of the teaching staff. 
The results claimed for improvement in the condi- 
tion of the children where the usual system prevails, 
and the luncheon is served on the cafeteria plan, with 
the stipulation that one essential dish, generally a 
thick soup with bread and butter, must be purchased 
by every child before he can secure sweets, cannot be 
said to establish the value of the school lunch as an 
educational factor nor even as a health-making fac- 
tor, the inference to be drawn is rather against the 
unsatisfactory conditions obtaining in the average 
home of the community concerned. 

The desirability of the mid-session luncheon of 
milk or cocoa as an educational experience seems 
evident aside from the probable existence in any 
school population, of children whose breakfast has 
been inadequate.* When it is recalled that much of 
the difficulty over the eating of breakfast, and of the 
hurried conditions attending luncheon in many homes 
as well, is directly related to the penalties imposed 
by the school on late-comers, the desirability of better 
adjustment between the schedules of the school and 

* See Appendix D. 



AN EDUCATIONAL PROGRAM 245 

home with relation to this particular point suggests 
itself. Lengthening of the noon hour to include a 
rest period at home for the younger children would 
probably be attended in many communities with bet- 
ter results than we were able to secure at P. S. 64. 

Except for the special provisions at Christodora 
House during our first term and in the open-air 
classes, the conditions we were able to provide with 
regard to rest periods were really little better than 
those attending dramatic experiences. As such they 
served a purpose but their functioning as true 
advantageous factors is to be questioned. 

The possibilities and responsibilities of the school 
in regard to the advantageous factors related to 
bodily activity, habits with respect to ventilation, 
and emotional attitudes, are probably of greater 
importance to health than those attending any 
routine experiences it may supply as to food and 
rest. Indeed we cannot properly estimate the 
part these might play in the establishment of 
health habits and increased vigor, unless we first 
conceive of a school environment successfully 
affording optimum conditions in regard to each, 
continuously throughout the school day, the school 
year, and the years of school attendance. If the 
total influence to be exerted appears a fairly con- 
siderable one viewed in this perspective, what is to 
be said for the present general adherence to seden- 
tary traditions, questionable winter atmospheres, 
and frequency of nervous tension and worry in our 
school-rooms? Unfortunately science has not yet 
spoken on these matters with sufficient definiteness 
to make her message to the school an unmistakable 



246' HEALTH EDUCATION 

one. Comparable experiments carefully planned 
with a view to ascertaining comparative results in 
growth under differing school environments are evi- 
dently needed before general progress in these 
directions can be expected.* 

Provision for enlistment of the children's coopera- 
tion with regard to advantageous factors must in 
the last analysis depend on the attitude of the 
school's teaching staff, and especially on the class 
teacher's appreciation of their essential values for 
health, and of their scientific and social interest. 
Constant contact with an adult whose own attitude 
toward health is informed and creative, must ever be 
the most potent of influences the school can bring to 
bear on the development of a health program, and of 
a tradition of health within the school. Under such 
influence the facts of daily environment and routine 
deliver their true message, and are raised to their 
true dignity. 

So far as the experiences offered by advantageous 
factors lead on to wider fields of interest, an educa- 
tional program of very special value may be de- 
veloped, although it may have little increased signifi- 
cance as a health program. The more modern types 
of school curricula where subject matter is definitely 
organized about the child's natural interest in food, 
shelter, and clothing, thus present special possibili- 
ties for supplementing the health program and will 
in turn be reinforced by it.f 

* See Appendix D — where an experiment of the kind is outlined. 

t For illustration see Goodlander, Mabel E., Education through 
Experience, Bui. No. X, Bureau of Educational Experiments, 1921 — 
where a number of class projects in food study (fourth grade) are 
described. 



AN EDUCATIONAL PROGRAM 247 

This will be especially true of those age periods 
chosen for the more intensive health programs. 
Food experiences offered by the school can probably 
be provided to the best advantage in connection with 
such programs. When necessary adjustments can 
be made to permit such first-hand experiences as the 
selection, purchase, preparation and serving of food 
by the children themselves, the informational con- 
tent incidental to such activities will greatly enrich 
the experience and the children's cooperation will be 
easily enlisted. Such activities should be organized 
from a viewpoint somewhat different from that 
usually held by the Domestic Science Department, in 
that the specific object should be, not so much the 
technique of cookery, as the study of foods, their 
values and place in the dietary. 

The content of such a series of lessons should be 
determined principally by the recognized need for 
broadening the dietary of the young child, and there- 
fore the emphasis should be placed chiefly on fresh 
vegetables, cereals, milk dishes and eggs, as the types 
of foods with which the home generally experi- 
ences the greatest difficulty in establishing satisfac- 
tory dietary habits. Simple equipment and simple 
methods of preparation are all that should be con- 
sidered in such a course of instruction for elemen- 
tary grade children. A most important factor how- 
ever is the provision of opportunity for the class to 
serve and eat their dishes, and thus secure the effects 
of the group appeal in acquiring a taste for new 
foods. In connection with such experiences we must 
appreciate that the program that educates to the 
importance of caloric intake, without special em- 



248 HEALTH EDUCATION 

pliasis on conceptions of balanced feeding and vita- 
mine intake, is inadequate. - 

Our initial program for diet and school feeding 
especially emphasized the importance of caloric in- 
take and in this followed the general lines prescribed 
by Dr. Emerson. Insistence on the elimination of 
tea and coffee, and on milk as an essential of the 
child's dietary, however, adds to his program some 
additional elements of importance, and the emphasis 
on cereal foods is a particularly practical method of 
supplementing the dietary with inexpensive carbo- 
hydrate foods, with the least possible danger to 
interference with the family budget and customary 
menu. Our experience seems to indicate the insuffi- 
ciency of this simple program, for a community of 
the kind in which we were working. Acquaintance 
with the dietaries of the homes shows lack of knowl- 
edge as to balanced diet, lack of knowledge as to 
vitamines, their place and importance, as to fats and 
the ability of young children to digest them, as to 
the peculiar properties of milk, and as to the undesir- 
ability of condiments especially in the diet of the 
child. Incomplete as present knowledge in regard to 
food properties must be admitted to be, very con- 
siderable progress in this field of science has been 
made in recent years, and any program of health 
undertaken in the school must take cognizance at 
least of the best authenticated facts of recent labora- 
tory experiment. 

THE CORRECTIVE PROGRAM 

While the true starting point for an educational 
procedure is the development of the general health 



AN EDUCATIONAL PROGRAM 249 

program with prevention as its aim, the school can- 
not ignore those children whose physical condition 
indicates the need of corrective measures and special 
care. For them a corrective program supplemen- 
tary to the general program must be arranged, but 
many of its details and provisions will of necessity 
vary with the varying conditions offered by the 
homes of the school community, and the adequacy of 
the health provisions incorporated by the school in 
its preventive program. In general we must antici- 
pate that special provisions affording advantageous 
factors will be a necessary part of the corrective 
program inversely to the proportion in which the 
home and school environments afford them. There 
are still many questions to be answered, however, as 
to the relative value of differing provisions especi- 
ally those relating to food intake and air, before our 
use of advantageous factors can become scientific 
and correspondingly efficient. Further experiment 
is needed to establish the place and character of the 
school lunch in the corrective program, and special 
research as to the effect of varying conditions of 
temperature and ventilation on the nutritional proc- 
esses and growth, must determine the place of the 
open-air class and the open-window room.* 

Whatever the special needs of a given community, 
the essential provisions of the corrective program 
must concern the extension of the school medical ser- 
vice to provide special examination, diagnosis, and 
observation, for children whose nutritional status is 
in question, as well as for those presenting obvious 
defects or symptoms of infections and diseases. In 

* See Appendix D. 



250 HEALTH EDUCATION 

addition to underweight for height and age, over- 
weight for height and underheight for age must be 
included in our conception of defective nutritional 
status if the program is to be in any sense complete. 
The first function of the school medical staff, then, 
will be to determine cases needing special physical 
care, improved regime or medical treatment, and to 
inform the home of its findings. Where the home 
cannot supply the necessary medical care, the school 
medical staff must be prepared to assume the re- 
sponsibility for arrangements with the various hos- 
pital and other agencies in the community, as was 
so generally done at P. S. 64. Here again the 
character of the community must largely determine 
the actual relationships to be established. 

THE STAFF 

"When we review the foregoing implications for 
school procedure with the necessary members and 
personnel of an adequate staff in mind, the following 
conclusions force themselves to attention: 

The positive health program demands a con- 
siderably increased school staff. 

Its success must depend on a personnel capa- 
ble of coordinating the requisite knowledge and 
techniques from several professional fields. 

The relative importance of special types of 
technical training will not be the same for the 
preventive as for the corrective program. 

Numbers. — It will be realized that at P. S. 64 
our staff were entirely concerned with problems 
of corrective work, and our experiment amply testi- 
fies to the size of the corrective program in that 
school community. The work, as reported, in- 



AN EDUCATIONAL PROGRAM 251 

eluding physical examinations, weekly measure- 
ments, individual and class instruction, home 
visiting and parents' meetings, and arrangements 
for cases needing special consultations, examina- 
tions or treatment of defects, with, in addition, 
the measurements of the control groups, consti- 
tuted a really arduous program for our nutri- 
tion workers, who were able to care for an average 
of but 40 children each, and who felt keenly the need 
of more extensive provisions for medical care 
throughout the experiment. Moreover, the de- 
mands on the physician's time were relatively in- 
creased. Because of the diversity and importance 
of the causal factors underlying malnutrition, diag- 
nosis of the condition requires care and experience 
on the physician's part. Thus, in any adequate plan 
for a corrective procedure, physical examinations ar- 
ranged for the children found to be underweight must 
be given a longer time allowance than is customarily 
provided in schools, and the number of under- 
weights that can profitably be examined in succession 
is limited by the tendency for the procedure to be- 
come a mere routine, where one child after another 
presents no clearly defined symptoms beyond those 
of poor general condition. Six or eight under- 
weights probably represent as many cases of this 
kind as one physician can profitably undertake to 
diagnose in succession. Beyond the mere statement 
that an increased personnel is required, however, it 
is hard to draw just inferences as to the probable 
number of workers needed in a different adminis- 
trative situation, where the corrective program is 
in the hands of the regular school medical staff and 



252 HEALTH EDUCATION 

is supplementary to an adequate preventive pro- 
gram. It will be evident, too, that the initiation of 
any health program will inevitably demand more 
time and effort than should be necessary subse- 
quently. After physical defects have been largely 
corrected, parental cooperation established, and 
community understanding secured, the proportions 
of the program will be correspondingly reduced. 

We may conclude from our experience, however, 
that unless an adequate staff is provided for the cor- 
rective program, its demands will absorb the atten- 
tion of the workers, and overshadow the claims of 
the preventive program. Thus, although our pro- 
visions for health should start with those for pre- 
ventive work, practically, the existing need for cor- 
rective work must always be supplied before the 
time and thought of the workers engaged can be 
given to very much else, and our personnel there- 
fore must be definitely planned to cover the correct- 
ive work in addition to the general program. 

Personnel. — The principal techniques employed 
in the nutrition class are those of the physician and 
nurse, of the social case worker, and of the teacher. 
While the contributions of other technically trained 
workers are also essential, success in the main de- 
pends on provisions for the combined medical, 
sociological and educational attack, and the organi- 
zation of the work to permit the most effective con- 
tribution from workers in each of these fields. If 
we analyze the chief provisions of both the cor- 
rective and preventive programs, we will find these 
techniques represented with somewhat differing 
emphasis. 



AN EDUCATIONAL PROGRAM 253 

The preventive program must provide for (1) or- 
ganization of the school's resources for health; in 
respect to physical examinations and record-keep- 
ing ; environmental conditions and equipment ; effect- 
ive cooperation of the class teachers and of special 
teachers, especially in the departments of physical 
training, of home economics, and science; (2) en- 
listment of the community and cooperation of the 
homes, through publicity, adult education, parent- 
teacher programs, and organization of the forces 
influencing public opinion. 

The corrective program must provide for (1) spe- 
cial examination, observation and diagnosis, with 
individual instruction and advice, for children whose 
physical examination indicates specific problems or 
lowered general condition; (2) individual follow- 
up to secure special provisions for care from the 
family physician or hospital agency, in the homes 
and at school. 

That is, the preventive program is primarily a 
teacher's program, dependent on physiological 
knowledge and the physician's advice to be sure, 
but essentially concerned with problems of school 
organization and teaching techniques, and with a 
supplementary program of adult education that calls 
for community social work rather than for social 
case work. It is evident that professional and tech- 
nical qualifications for corrective work will not in 
themselves constitute the necessary qualifications 
for the personnel of the school's general health pro- 
gram, and the subtle differences of temperament, in- 
terests, and attitudes that characterize the worker in 
the medical field, in sociology, and in education, must 



254 HEALTH EDUCATION 

be considered in addition to any praeticnm for train- 
ing. The starting point of interest for the physician 
and nurse is, in the great majority of cases, ill- 
health. Pathology rather than hygiene absorbs their 
attention, and similarly, the interest of the" sociolo- 
gist is, for the most part, centered on poverty and 
its problems. At the same time the physician, the 
nurse, the case worker, as a rule, have but little 
understanding of recent developments in education- 
al techniques, and, like most of the community, base 
their conceptions of acceptable procedures on the 
experiences of their own school days, 15, 20, 30 years 
ago as the case may be. The modern teacher has 
some very good grounds for instinctive reservations 
toward the "educational programs" suggested by 
outside enthusiasts, whose ideas of teaching in nine 
cases out of ten will be found to consist in the di- 
dactic presentation of additional subject matter. 
Physicians in particular seem, as a profession, to 
lack the necessary attitude for teaching children, 
possibly because their consciousness of the great 
body of subject matter incident to their own pro- 
fessional training renders them especially suscept- 
ible to the temptations of didacticism as a "short 
cut" to knowledge. Our nutrition class for the first 
term clearly showed the educational limitations and 
fallacies incident to a school procedure in the hands 
of specialists untrained in educational techniques. 
It seems evident that our positive health program 
must be entrusted to a new type of worker who shall 
be at once ahygienist and a teacher, who shall as such 
cooperate with the teaching staff on the one hand, 
and with the medical staff on the other, supplement- 



AN EDUCATIONAL PROGRAM 255 

ing eacH without superseding either. The advisa- 
bility of freeing such a worker entirely from respon- 
sibility for corrective measures, and thus ensuring 
individual effort and attention for the development 
of a constructive health program will be evident. 
The organization of the school's total resources for 
health, and the resulting modifications in the exper- 
iences afforded to all children, should relieve the 
corrective program from the necessity for class in- 
struction, and modify the requisite qualifications 
for its personnel accordingly. 

If the preventive program is primarily a teacher's 
program, the corrective program, on the other hand, 
is primarily the physician's and should be directed 
by him. The great variety of the causal factors in- 
volved and the serious nature of many of them argue 
the importance of the physician 's services here, and 
the danger of entrusting the responsibility for diag- 
nosis, or advice as to remedial measures, to any 
worker of narrower experience or less thorough 
training. 

It will be evident that the services of the visit- 
ing case worker are necessary, to supplement 
the work of the physician and school nurse, and that 
the demands of the situation offer a distinct status 
for a medical social worker. In a community like 
that of P. S. 64, a dietitian's training is of undoubted 
advantage for the home visitor. Success, however, 
is primarily dependent on the case worker's attitude 
and technique, and in such a community the dieti- 
tian without these can hardly be expected to succeed. 
The place of the case worker and dietitian in school 
communities where better economic conditions ob- 



256 HEALTH EDUCATION 

tain has yet to be defined, but development of the 
school health program in such communities will 
probably modify our present conceptions as to the 
scope of such work, and the necessary qualifications 
and training of the worker. 

Summary 

The health program that shapes itself from the 
foregoing interpretations must not discourage by 
reason of its proportions. It should lead rather to 
a new realization that "public health is purchas- 
able," and that the purchase price must include as 
always initiative, ability, and continued conscien- 
tious effort. So far as the experiment at P. S. 64 
bas broken ground by uncovering problems and pos- 
sibilities, we believe its record will prove service- 
able to the cause of public health and public educa- 
tion. The chief points in our thinking to-day as we 
bring this study to a close may be briefly summar- 
ized as follows : 

The efficient program of health education must 
recognize the primary importance of nutritional 
status as a basis for estimating general physical 
condition among children. Such recognition in- 
volves a considerable program of scientific research, 
community enlightenment and school adjustment. 

Results of the health program should be evaluated 
currently through individual records of growth in- 
crement and nutritional status. Not merely pre- 
vention of lowered physical condition and approxi- 
mation to currently accepted "norms" should be the 
aim, but physical vigor and height and weight in- 



AN EDUCATIONAL PROGRAM 257 

crease in excess of our present standards for race 
and stock. 

The resources of the school for supplying the 
chief provisions essential to the success of an educa- 
tional health program are greatly superior to 
those at the command of any other agency. Great 
as the initial task may be, the school can eventu- 
ally transmit the necessary conceptions to the 
community and enlist the cooperation of both child 
and home, and it is the only agency organized to 
reach every child and every home. It is the only 
agency, therefore, that can advantageously secure 
the data necessary for research from all sections of 
the community, and present a true cross-section of 
child development from every type of home, and 
from adequate numbers of well children, of differing 
racial strains and differing economic levels. 

The preventive program of health education must 
be basic, an integral part of the school's general 
thinking, administration and equipment. It cannot 
be successfully developed merely as a procedure to 
supplement the corrective program. 

The school can greatly strengthen its educational 
practice by making the adjustments in its equipment 
and procedure demanded by the health program. 
On analysis these will be found consistent with 
successful educational experience. Indeed our 
health program well exemplifies what has been called 
''the normal estate of effective learning, namely that 
knowledge-getting be an outgrowth of activities hav- 
ing their own end."* 

* Dewey, John, Democracy and Education, The Macmillan Co., 1916, 
p. 229. 



APPENDIX A 

Distribution Table of Percentages Over and 
Underweight 

This distribution table was compiled from the re- 
sults of measurements taken in February 1918. It 
therefore reflects the comparative status of children 
in the several grades represented at a season when 
the period of maximal weight increase is over and 
before effects from the period of minimal weight 
increase have become appreciable. 



258 



APPENDIX A 



259 



distribution table of 894 children according to percentage 
Over- and Underweight * 



Percentage 


Grade 
VII 


Grade 
VI 


Grade 
V 


Grade 
I 


Terman 


Open 
Air 


67 








1 






49-44 


1 




1 








44-39 














39-34 


2 


1 










34-29 




1 




1 


1 




29-24 




4 










24-19 


3 


2 




1 


1 




19-17 


1 




2 








17-15 


4 


2 


1 


1 






15-13 


3 


8 


3 


2 






13-11 


7 


5 


3 


2 


2 




11-9 


3 


8 


4 


6 


2 




9-7 


14 


9 


7 


13 


1 


1 


7-5 


8 


11 


9 


24 


2 


2 


5-3 


17 


19 


11 


24 


12 




3-1 


13 


23 


13 


27 


3 


3 


1-1 


16 


31 


6 


35 


9 


2 


-1-3 


23 


28 


13 


24 


8 


1 


-3-5 


22 


24 


16 


29 


3 


4 


-5-7 


11 


30 


11 


22 


6 


5 


-7-9 


8 


12 


10 


14 


11 


1 


-9-11 


6 


10 


4 


13 


2 


2 


-11-13 


7 


6 


5 


11 


2 


2 


-13-15 


3 


2 


2 




2 




-15-17 


1 


5 


1 


3 


2 


1 


-17-19 




4 


3 


2 






-19-24 












1 


-24-29 






1 








-29-34 






1 








Total. . . 


173 


245 


127 


255 


69 


25 



* Computations for this table were made by Dr. David Mitchell 
and the figures originally published in his article, Malnutrition and 
Health Education, Pedagogical Seminary, March, 1919. They are 
reproduced here by permission of the Pedagogical Seminary. 



APPENDIX B 

Individual Record Sheet 

The record form used by us at P. S. 64 is a single 
sheet, 8" X 14%", folded twice to make a six page 
folder of 5"X8" filing size. It may thus be used to 
hold supplementary sheets or correspondence rele- 
vant to the case history but is definitely planned 
to cover the essential facts of the physical history 
and examination, social history and class record on a 
single form and thereby avoid as far as possible the 
necessity for additional records. While further ex- 
perience has suggested a few changes of detail in 
this record, space for some additional notations, as 
for stool and urine examinations, and elimination 
of some non-essential details, it has been found 
fairly satisfactory for our purpose and of particu- 
larly convenient size for filing. 

The faseimile of page 1 shows at the right the items for 
identification, name, address, etc., printed on page 5 but 
appearing at the top when the record is folded and filed. 
Page 1 contains the final summary and weekly record for 
19 successive weeks and this is extended to include 44 weeks, 
the spacing for the last 25 weeks covering page 6 when the 
record is folded. 



260 



APPENDIX B 



261 



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I I 1 I I M 1 i i ,1 



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262 HEALTH EDUCATION 



PHYSICAL CXAHINATION 



INSPECTION: Blight IS dull unrolls x/ phlegmatic aprfhcflfl 

DEVELOPMENT: Good fate a' poor MUSCLES: Fin flatty 

CEKBBAL CONDITION: Good fair if poor 

BEAD: Normal • • Dosxa prominent Pedlcull V^ 

■IBS: Trolls eoual V Btnct to llsht— dlatance i/ Motions: nor l/abac?. RaHarlM 

NABEfJ: Gear v erasted Mucous discharge Spar Desisted septan 

MOUTH: Norsect oiks •/ Cough Barnes Moans Mens*, soimej pels V^umutta 

TOMOUB: Nermel mew \s dry at whllo coat ttrownjoi end 

THBOAT: Normal congested granular J<„ mucons 

TONSILS: Normal largo burled cryptic >C« mfiamod abeeat 

GLANDS: Normal enlarged Ant-cerrlcal -J~t- Poat-carr. + Epttrasear. 

TEETH: Good No. decayed Approximation good 1/ poor tnained 

BARS: Rlshtdraei: Normal •* dull retracted bulging; Ccramso 

loft drum: Normal dull \S retracted bulging 

HEART: Area dullnaog is • 5" o- m. left mid-sterns! duo 
/• $ em. right " " 

Apex 4th Cth l/ Oth apace in nlpplo Ua» 
c, m. outside "• " 
c m. Inside ** m 
Action: regular Irregular *^ Sounds: dear fapea 

Thrill: present nona */^ A3 T2 

Uunnun: none 

aoft sys. •'f opes l/ I j^^ff ant axtnear I 
loud aye. at I pulmonis 1 tr to < mW ' " 
diastolic I aorUc I I angle of i 

LUNOB: Besonance good throughout v*" D'EspIns to / dor. termors 

Besplratlon " " [/~ 

ABDOMEN: Normal y^ largo lax dutondsd trmpaaMc Sexalef 

Bornla 

Liter: dullness 6? space rib to costal border nipple Us* 

Spleen: felt not felt tV"* 

GENITALS: Normal v^~ Prepuce: long adherent (Iminmam t>^ 

EXTREMITIES: E. J.: present and «ine] l/^* absent 

Edema " •• ,>■"" 

SKIN: SmMthO^^yTongb clear Scars Tacdnatloo: present (/ aheont 

Facsimile of page 2 — Individual Record Sheet. — Nota- 
tions on Physical Examinations, 



APPENDIX B 263 

PHYSICAL EXAMIMATIOW (Celrtlatrt) 



SPIKE: Normd t/ iHtfertl cnrratore— rich! Wl 

Bouitca Bound «aoulda» l/~ Wlmol Scapula* tV' 

CHEST: Nomall/ fcama «•» ***** > MMB Hlnww 

FECT: Arcnea: good iS jmraited Statton: mod aV^ toot 

Catt: t^ 

diagnosis: <f<nA^u«L. 5Xi«-«»-<-«AdLR-oo > -»-djujuJLrtL* whamA. 

BBDOMMEKDATIONS: { 0-***A*Ao «*»«^X?. 

Role: Ctedr V todlcous defect present Lino drawn ihrousn word Indicate* eaamlncd and com 

Infllcat* gerrao bf 4- gjg: 



SUPPLEMENTARY INFORMATION 






KXAHBKD Bl ^^'^-St^aJk-UjLA. DA™ 4 .►■£.3'. (S^ 

DICTATED TO Q.'S m-'S r 

Facsimile of page 3 — Individual Record Sheet. — This 
page continues the notations made during the physical ex- 
aminations and affords space for supplementary notes on 
physical condition. 



264 



HEALTH EDUCATION 



S0C1AI FACT9 



INFORMATION REGARDING MEMBEKS OP FAMILY 






M 

a. 



13 
12. 



Haiti Defects 






S|m***„ 



U«cS. 



•Include etlll-bonl and mlacarrlaa'ea In order. 



&<rdJ}\. 



INF0E1IATI0N ItEGABDINO BIETH AND INFANCY 
Bom at full term \s labor /l 

Breast-fed | \ (^jj Bottle MIxeiJ 



Condition' at birth 



jr. 



lit Tooth at 'lfeg^WaUudat V3 Bpotoat (if 



rnfivious diseases <with 


DATES) 






Meula lJ-lA>ur». 


Cblchen-poi ■— 


TonaUItla — — 




Mumps — . 


BheuzoaUsm , - 


CooTUlatoni .— 




•earlet-ferer -™ 


Hanlmdtis — — ""' 


Chora* 




Diphtheria — 


Pneumonia __ 


Operation* __ 




Wnoopinff-eoutH »_» 


Bnmchltla — ■" 







OSNEEAL HEALTH AND HABITS 

Appetite (reperfsliy for brealrfant) CT.I J^ Nall-bltlnj " ™ * 

«awlarlty of meal* f^ j^g, Bed-wetuoi — 

eannlaiita -j oJZ,\~k. i>-f fHfVfl'l a «° 

t^^ua. S*j^>**- * Hastiest — 

Bowels W2 *-e« Na *" *° 01 *" i. 

Headache __ O ~ " bed ♦ 

Earache __ tnu) oa boon /© —» §"" JO 

FTeguent colds — 

CONDITION OP FLAT BENT /£". fi*0 Ko. Boom 3 

, Ona ^" inside mora * RfruAJL. 



$>$.£&. A*o. *?«***<, \%tg 



Facsimile of page 4 — Individual Record Sheet.— Social 
facts and health habits are recorded on this page. 



APPENDIX C 265 



SUPPLEMENTARY JHFO KATIOH 



TauuAiJUj. u*aJ<<L- -hjm+jJL •^ J ~k*~ r&-*Ou*eLKiJU'~ 

3«>MLo /5-».<<» «^-«.eA, 'WXAJkyv. WieuO^ 0-4ju4aJu\ . 

A-Ouumi iAx«^^aJLL*a^ ^o~^iP its- -t^irv^ot_ 



S- 












If 

■b 
o 



r 



it 



Facsimile of page 5 — Individual Record Sheet. — Sup- 
plementary information recorded on this page covers 
social facts and miscellaneous details. 



APPENDIX C 

Specimen weight charts with adaptations made 
during the course of the experiment. 

The weight charts used at P. S. 64 were of heavy 
' white paper 24"X19". Charts Xa and Xb * show the 
original form used during the first school term. 
The name of the child is placed in large letters 
across the top and dates of the weekly class meet- 
ings are recorded just below in the first two rows. 
Stars appearing in the third and fourth rows fol- 
lowing the words " Lunches" and "Best" indi- 
cate that the child has followed his prescribed 
regime in regard to lunches and rest on each 
day of the week so marked. Figures in the left- 
hand column indicate pounds and are determined 
by placing at the bottom of the column a number 
two or three pounds below the actual weight of the 
child at the time of enrollment. Figures in the last 
row following the word ' ' calories ' ' indicate the num- 
ber of hundred calories averaged per day as esti- 
mated from the 48 hour record taken weekly. The 
heavy irregular line running across the chart is the 
record of the weekly weight taking showing the suc- 
cessive increments and losses of the individual for 
whom the chart is kept. Dotted lines indicate holiday 
periods and absences. The heavy straight line above 
is the "Line of Normal Expected Gain" and repre- 

* Keproduced by permission of the Pedagogical Seminary. 

266 



APPENDIX C 267 

sents the week to week weight increment for a child 
of normal weight and of the same height and age. 
(For»computation of this line see footnote p. 51). 

Xa shows a satisfactory record. The child in 
question was 8 pounds, 9%, underweight when en- 
rolled and in 13 weeks gained 9y 2 pounds, bring- 
ing him within 2% of normal. It will be readily 
appreciated that where the individual makes this 
kind of response, the line of normal expected gain 
acts as an incentive to effort, and it will be equally 
clear that for the child Xb the effect of the line of 
normal expected gain is discouraging to effort. 
This child was lSy 2 pounds, 17%, underweight when 
enrolled and at the end of 19 weeks had gained but 
3 pounds and was still 13^ pounds, 16%, under- 
weight. 

Charts Ya and Yb * show the form used for the 
fifth grade and open-air classes during the second 
winter and have the line of normal expected gain 
paralleled by a line of "Individual Expected Gain" 
that starts from the point indicated by the child's 
actual weight at enrollment and progresses by the 
same weekly increments. The two lines thus form 
a zone within which progress may be considered 
achievement. Ya is a low percentile case showing 
satisfactory progress: He was 5 pounds, 8%, un- 
derweight when enrolled, gained 8 pounds in 30 
weeks and was then within 1% of normal. Yb on 
the other hand, is a high percentile case, whose re- 
sponse is unsatisfactory. He was 12 pounds, 17%, 
underweight when enrolled and after 30 weeks was 
14 pounds or 18% underweight. It will be appar- 

* Reproduced by permission of the Pedagogical Seminary. 



268 



HEALTH EDUCATION 



Dak. fib Match April May dum. 

,22 I 6 15 22 Z9 5 12 19 26> 3 10 17 2413/ *7 14 Z\ 



Lunthei 


* **&& *^* 


Rest 


* #*#*#&■&* 


106 




105 




/04 




103 




102 




101 




{00 




99 ^~ 




93 




91 


Holiday /^^r 


36 


ty 


95 


94 


/s/ 


S3 


/i 


$2 


/ Co/c* 


3f ^J 


r 


SO " 




69 




loo 


2J J* 2o 29 £9 Z$> 2b Z9 Zl 



CHART Xa. 

Showing Line of Normal Expected Gain — a Satisfactory 
Record. 



APPENDIX C 



269 



Odtttkbcuary Morch April May June 

S 12. 19 Z6 5 /2 19 26 2 9 l& 23 30 7 I* Zl Z& + II Id 



ltinch*$ 
Rest 
85 
8+ 
83 
62 
81 
80 
79 
78 
77 
76 
75 
74 
73 
72 
1\ 
70 
69 
68 
61 
66 
65 

Caloric ZS 2 7 



# * 

* * %? % 



# * # 

* * * 



* 



# * * * * # 



tioho* 




27 .22 



a6 2J 



23 



CHART Xb. 

Showing Line op Normal Expected Gain — an Unsatisfactory 

Record. 



270 



HEALTH EDUCATION 



-M J 






71 

70 



Uoirrajki 4, 

Par Gal. Underwent 



65 Jb 



11 I3 18 25 37 17 1*18 13 M U « 17 19 18 « 83212SS9 

j •» « > 4 t a » io ii u u m ii it i7 h 19 u ii a u u a i 




CHART Ya. 

Showing Zone Formed by Line of Normal Expected Gain and 
Line op Individual Expected Gain — a Satisfactory Record. 



APPENDIX C 



271 



*t, A/mCnA- /* 




73 
72 
71 

70 
69 
68 

67 
66 

65 
64 

63 

62 

61 

60 




CHART Yb. 

Showing Zone Formed by Line of Normal Expected Gain and 
Line op Individual Expected Gain — an Unsatisfactory Record. 



272 HEALTH EDUCATION 

ent that for this boy the struggle to approximate 
his individual line of expected gain was unsuccessful 
during the season of minimal increase, and the pres- 
ence of the line of normal expected gain could have 
had no significance for him except as a discourage- 
ment. 

Some changes in addition to the line of individual 
expected gain will be noted on these charts (Ya and 
Yb). Actual dates of the class meetings have been 
replaced by their numbers, 1, 2, 3, 4, etc., indicated 
by the figures in the fourth row from the top. Rest 
periods and lunches are recorded in the first and 
second rows and the stars used are supplemented 
by figures indicating the number of days during 
the week that the regime was followed, the star 
signifying that the regime was observed every 
day of the school week. The records of caloric in- 
take follow in the third row. The three last rows 
are used to indicate the presence of defects needing 
correction and the taking of tea and coffee. A black 
sticker placed in the row opposite the words" Ton- 
sils, Adenoids" shows operation has been recom- 
mended and is repeated every week until removal, 
when a gold star is used. (See chart Ya where op- 
eration was performed in the eighteenth week and 
is followed by a loss of 3 pounds in weight and 
rapid gain after 3 weeks absence.) A gold star was 
also used to record the greatest gain in pounds made 
in each class during each week. For this Ya re- 
ceives three gold stars at different points in his 
progress, and Yb in spite of his poor record later, 
receives one the third week after his enrollment. 



APPENDIX C 273 

Dental defects are indicated in the row below by- 
figures showing the number of defective teeth found. 
As these are treated the figures are reduced. Fig- 
ures in the last row, following the words, "Tea, 
Coffee," indicate the number of times these stimu- 
lants were taken during the week. 

Chart Z shows the form used for the first grade 
children during the last winter of the experiment. 
Only the line of individual expected gain is used for 
comparison with the week to week increments and 
all gains in excess of that appear as achievement. 
Thus the efforts of the children are directed to 
"beating their own record" and the greater appar- 
ent success attending their attempts serves to stim- 
ulate further endeavor. Z is a high percentile case, 
being 7 pounds or 16% underweight when enrolled. 
After an initial gain of 3 pounds in the first three 
weeks he averages from 3y 2 to 1V± pounds in excess 
of his expected gain at each weight taking for 32 
weeks when he is Sy 2 pounds, 7.5%, underweight 
for height. One other feature added to the chart 
in this last year was the red crayon dot by which 
the child himself recorded the result of the weight 
taking under the nutrition worker's supervision. 
He placed the dot in the proper square and the 
weight line was filled in by the nutrition worker 
afterwards. 

In the light of subsequent experience, some fur- 
ther modification of the weight chart, or at least of 
the line of expected gain to reflect seasonal varia- 
tion suggests itself. It will be evident that these 
lines as computed on all charts, whether for 



274 



HEALTH EDUCATION 



M*N 43 

«** 36 



-16 



47 
46 
45 
44 
43 
42 
41 
40 
39 
38 
37 
36 
35 
34 
,33 

AM* 

la. 




Showing Adaptation Finally Made Using Only Line op Indi- 
vidual Expected Gain. 



APPENDIX C 275 

Normal Expected Gain or for the Individual Ex- 
pected Gain represent a rate of increase too low 
for the season of maximal increment and too high 
for the season of minimal increment. 



APPENDIX D 

Relative efficiency of differing provisions afford- 
ing advantageous factors in the school environment. 

Before our provisions for health education can be 
placed on the most efficient basis, a considerable 
program of experiment remains to be undertaken. 
The relative value of various provisions for supply- 
ing advantageous factors in the school environment 
has yet to be determined, and experiment is espe- 
cially needed in respect to provisions for school feed- 
ing and ventilation. This can only be accomplished by 
consistently following such a program as was at- 
tempted in the first year of our work, that of estab- 
lishing parallel groups of children on a basis as 
nearly equal as possible, but with different variables 
as points of comparison. 

Comparable groups of children should be studied 
under varying conditions of ventilation with a view 
to determining more definitely the influence on 
growth of optimum conditions in respect to temper- 
ature, humidity, and movement of air. The facts 
of seasonal variation establishing the fall months as 
the period of maximal weight increase, suggest the 
favorable influence for nutritional processes of var- 
iable, but not extreme temperatures and open win- 
dows, in comparison with extreme outdoor cold and 
the heated indoor atmospheres, with low humidity, 

276 



APPENDIX D 277 

and lack of air currents, that characterize our win- 
ter conditions in the latitudes of New York and 
Boston. Comparison of the results secured in the 
open-air and fifth grade classes during the second 
winter of our experiment appears to confirm the 
hypothesis that conditions of ventilation materially 
influence the nutritional processes, and that week to 
week observations of growth in children, under con- 
ditions calculated to isolate the factors of tempera- 
ture, air movement and humidity, would result in 
some definite accessions of knowledge in respect to 
the importance of these as advantageous factors in 
the school environment. The numerous experiments 
previously undertaken in this field have yielded only 
negative data in respect to the effect of ventila- 
tion on health, as in the case of the investigations 
conducted by the New York Ventilation Commission, 
or have attempted to draw conclusions from groups 
not strictly comparable, under conditions not strictly 
parallel in respect to other advantageous factors. 
This is true of the numerous comparisons attempted 
between open-air and indoor classes. Children of 
anaemic or pre-tubercular condition usually form 
the major part of the open-air groups, and are given 
the special provisions characteristic of the open-air 
class in addition to the modified atmospheric condi- 
tions. For years a battle royal has been waged in 
the schools by and against the advocates of open- 
air classes. But for the most part investigators have 
been concerned with comparisons of the learning 
process, and after reporting on the negative results 
obtained from these, have been content to confess 
that they have had no standards by which to evalu- 



278 HEALTH EDUCATION 

ate physiological effects.* Physiological effects, 
however, are precisely what the health program 
must consider. Especially is this true of a program 
that seeks to increase physical vigor through im- 
proved nutritional status. We must agree with Dr. 
Burnhamf that experiments to date have not been 
carried far enough. They are inconclusive so far 
as our problem is concerned. For this reason we 
suggest an extended study of week to week growth 
increments under at least four contrasted methods 
of ventilation found in our schools at the present 
time. This study should be undertaken with groups 
of children strictly comparable as to average physi- 
cal status, age period, mental ability and conditions 
of class environment. 

Since experience has shown that open- window and 
open-air classes must be provided with mid-session 
lunches, rest facilities, and frequent brief periods of 
bodily activity in cold weather, we cannot isolate 
the influence of atmospheric conditions in an inves- 
tigation of groups where an open-air class is in- 
cluded, unless we supply these special conditions to 
all the groups studied. Thus our investigation in- 
stead of contrasting standard school conditions with 
the special environmental conditions found in the 

* McCall, Wm. a., Proc. Conference Women Physicians. Vol. III. 
pp. 46-63, Womans Press, 1920. 

t Burnham, Wm. H., The Optimum Humidity for Mental Work, 
Pedagogical Seminary, Dec, 1919, pp. 311-329. "The experiments 
by the New York Commission strongly suggest that excess of tem- 
perature or the bad odors of stale air, or both these together modify 
the general metabolism since, as we have seen these investigators 
found that by working in bad air and overheated conditions the 
appetite of their subjects was diminished. Thus while for the time 
being no appreciable effect on the working ability was noticed, prob- 
ably continued work in these conditions would be injurious to the 
health and decrease efficiency, " 



APPENDIX D 279 

open-air class would add the advantageous factors 
of the open-air class (with the exception of atmos- 
pheric conditions) to the usual environment. In 
this way we might hope to isolate the effects on 
growth of the varying conditions of atmosphere af- 
forded by the following provisions : 

Open-air or open-window class with artificial heat to ensure a 
temperature of 55 degrees. (The generally accepted provision in 
latitudes like New York where extreme winter cold prevails.) 

Closed-window class with artificial heat and direct ventilation. 

Closed-window class with artificial heat and forced air ventilation. 

Closed-window class with artificial heat and forced, humidified air. 

A parallel series of observations on groups of nor- 
mal children, low percentile underweights, and high 
percentile underweights, under these varying condi- 
tions of environment, should prove of proportion- 
ately greater interest and importance. 

Comparable data on parallel experiments in school 
feeding should determine the character and place of 
the school lunch in a corrective program,, The 
school lunch for malnourished children had origi- 
nally but a single purpose, to fill the hungry, and pop- 
ular thinking on the subject to-day is largely colored 
by the eleemosynary character of its beginning. 
Soups and stews have been provided in our public 
school lunch rooms for many years with a view to 
satisfying hunger, and such returns in weight in- 
crease as have resulted have been accepted without 
question, because in the minds of those responsible 
for the menus, relief measures rather than stimula- 
tion of growth have been the major consideration. 
Increasing realization that the function of the 
school lunch in a corrective program is educational 
and remedial has not served to alter the character 



280 HEALTH EDUCATION 

of the menus generally offered to the extent that the 
newer conceptions of feeding demand. Questions of 
relative convenience, expense and tradition largely 
govern the selection of the foods supplied, and so 
simple a piece of research as the gathering of data 
on the comparative weight-getting value of the dif- 
ferent types of mid-morning lunches, whether of 
milk, of cocoa, of soup or of cereal and milk, remains 
to be attempted. We have no statistics by which to 
gauge the advantages of the mid-day dinner planned 
as a model balanced meal in comparison with those 
of a meal planned to supplement particular deficien- 
cies in the home dietaries. Yet every worker 
responsible for dinner menus in a corrective pro- 
gram is called on to decide between these two 
methods of attack. The dinners provided by the 
New York School Lunch Committee during the first 
term of our work were planned on the second basis, 
with a view to supplementing home dietaries that 
were conspicuously lacking in milk and vegetables 
and for the most part low in caloric value. The 
greater knowledge of food accessory substances that 
is rapidly becoming a part of general thinking 
to-day, suggests the desirability of still further 
departure from the model balanced meal when stimu- 
lation of growth is the specific aim in view. And 
thus the question arises whether the emphasis placed 
on milk and vegetables in our best current programs 
might not profitably be extended to include the 
liberal use of fruit juices and tomato juice, possibly 
of yeast, to stimulate appetite and increase vitality. 
Experience has pretty clearly shown that what- 
ever lasting results in growth are to be secured from 



APPENDIX D 281 

the feeding program, must in the final analysis de- 
pend on the modification of the home dietary as a 
result of tastes cultivated or convictions established 
through the school experience. Hence the relative 
efficiency of the school menu cannot be determined 
in advance merely by considering its constituent food 
values. Careful evaluation of the actual returns 
from various programs is the necessary basis for 
real progress in this field. 



" 



LIBRARY OF CONGRESS 



021 331 129 3 



